Marker Of Residual Disease Research Articles

Predictors of residual disease after debulking surgery in advanced stage ovarian cancer.

Optimal debulking with no macroscopic residual disease strongly predicts ovarian cancer survival. The ability to predict likelihood of optimal debulking, which may be partially dependent on tumor biology, could inform clinical decision-making regarding use of neoadjuvant chemotherapy. Thus, we developed a prediction model including epidemiological factors and tumor markers of residual disease after primary debulking surgery. Univariate analyses examined associations of 11 pre-diagnosis epidemiologic factors (n=593) and 24 tumor markers (n=204) with debulking status among incident, high-stage, epithelial ovarian cancer cases from the Nurses' Health Studies and New England Case Control study. We used Bayesian model averaging (BMA) to develop prediction models of optimal debulking with 5x5-fold cross-validation and calculated the area under the curve (AUC). Current aspirin use was associated with lower odds of optimal debulking compared to never use (OR=0.52, 95%CI=0.31-0.86) and two tissue markers, ADRB2 (OR=2.21, 95%CI=1.23-4.41) and FAP (OR=1.91, 95%CI=1.24-3.05) were associated with increased odds of optimal debulking. The BMA selected aspirin, parity, and menopausal status as the epidemiologic/clinical predictors with the posterior effect probability ≥20%. While the prediction model with epidemiologic/clinical predictors had low performance (average AUC=0.49), the model adding tissue biomarkers showed improved, but weak, performance (average AUC=0.62). Addition of ovarian tumor tissue markers to our multivariable prediction models based on epidemiologic/clinical data slightly improved the model performance, suggesting debulking status may be in part driven by tumor characteristics. Larger studies are warranted to identify those at high risk of poor surgical outcomes informing personalized treatment.

Serum Free Light Chain ratio: Utility as marker of residual disease in monoclonal gammopathies

Serum Free Light Chain ratio: Utility as marker of residual disease in monoclonal gammopathies

Clinical predictors of residual disease in hysterectomy following a loop electrosurgical excision procedure for cervical intraepithelial neoplasia grade 3

ObjectiveTo investigate the predictors of residual disease in a hysterectomy following a loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 3.MethodsThis retrospective study identified 421 patients with histologically confirmed CIN 3 who underwent LEEP and subsequently had a hysterectomy within 6 months. The clinical data included age, parity, type of transformation zone, cytology results, human papillomavirus (HPV) genotype test, endocervical curettage (ECC), and pathological data of LEEP and hysterectomy were obtained from the medical records. A logistic regression model was used to analyze the relationship between the variables and the risk of residual disease in the hysterectomy samples.Results186 (44.18%) patients had residual disease in the hysterectomy specimens. The predictive markers of residual disease following LEEP included positive ECC, positive margin of the samples from LEEP, type II or III transformation zone, HPV16 and HPV18 infection, and other high-risk HPV. HPV-18 positivity (OR, 7.13; 95% CI, 3.49 to 14.56; p < 0.001) and type III transformation zone (OR, 6.37; 95% CI, 2.91 to 13.94; p < 0.001) were the most indicative of residual disease following LEEP.ConclusionPositive high-risk HPV, particularly HPV18, positive ECC, the positive margin of specimens from LEEP, and type II or III transformation zone were reliable prognostic markers of residual disease following a LEEP for CIN 3.

Prognostic impact of postoperative circulating tumor DNA as a molecular minimal residual disease marker in patients with pancreatic cancer undergoing surgical resection.

We aimed to clarify the prognostic impact of postoperative circulating tumor DNA (ctDNA) shortly after pancreatectomy in patients with pancreatic ductal adenocarcinoma (PDAC). Preoperative and paired postoperative blood samples were obtained from 66 patients in patients with PDAC. Cell-free DNA was extracted from the plasma, and KRAS mutations, as a benchmark of ctDNA, were examined using droplet digital PCR. Disease-free survival (DFS) and overall survival (OS) were compared between patients with presence and absence of ctDNA. In univariate analysis, patients with detectable postoperative ctDNA showed worse survival than those with undetectable in both DFS (P=.034) and OS (P=.022). Multivariate analysis also revealed that the presence of postoperative ctDNA was an independent risk factor for recurrence (hazard ratio: 2.677, P=.011). In contrast, preoperative ctDNA detection did not affect long-term outcomes. These trends persisted in 34 patients with resectable PDAC who underwent resection after neoadjuvant chemotherapy. Patients with detectable postoperative ctDNA were more prone to developing hepatic recurrence than those with undetectable postoperative ctDNA (P=.039). Postoperative ctDNA, as a minimal residual marker, can be useful for predicting the risk of recurrence in patients with PDAC even after curative resection.

Prophylactic Donor Lymphocyte Infusion in Patients after Allogeneic Stem Cell Transplantation with Post-Transplant Cyclophosphamide Is Associated with Low Relapse Risk and Excellent Survival in Patients below 65 Years with Acute Myeloid Leukemia and High-Risk Myelodysplasia

BackgroundPost-transplant cyclophosphamide (PTCy) effectively prevents graft-versus-host-disease (GVHD) in allogeneic stem cell transplantation (alloSCT) with matched related and matched unrelated donors resulting in low risk of non-relapse mortality (NRM) (<10%). However, PTCy-alloSCT is associated with high relapse rates of approximately 20-30% after 1 year and 30-40% after 2 years (Gooptu et al. Blood 2021, Ruggeri et al. J Hemat Oncol 2018). Prophylactic donor lymphocyte infusion (DLI) may reduce relapse, although it may increase the risk of GVHD. AimTo provide evidence for reduction of relapse and improvement of survival by combining allogeneic SCT with PTCy and subsequent standardized prophylactic donor lymphocyte infusions (DLI) in a cohort of patients with acute myeloid leukemia (AML) and high risk myelodysplasia (MDS). Patients and MethodsSixty-five patients with AML (n=50) or high risk MDS (n=15) received myeloablative (n=15) or reduced-intensity (n=50) alloSCT with a matched related (n=8) or 9/10 (n=19) or 10/10 (n=38) matched unrelated donor. Based on modified ELN criteria, 10 AML patients were intermediate risk and 40 poor risk. GVHD prophylaxis consisted of PTCy, mycophenolate until day +30, and tacrolimus tapered from +70 (related or 10/10 unrelated) or day +90 (9/10 unrelated). All patients were planned to receive DLI at 6 months after transplantation at a dose of 3 x 10^6 CD3+ cells/kg in related and 1.5 x 10^6 CD3+ cells/kg in unrelated alloSCT. In poor risk patients (poor risk AML and high risk MDS) additional low dose DLI (0.3 or 0.15 x 10^6 CD3+ cells/kg in related and unrelated alloSCT, respectively) was planned one month after tacrolimus tapering (i.e. 3-4 months after alloSCT). In poor risk patients with a sensitive molecular or immunophenotypical minimal residual disease (MRD) marker (<0.1%) low dose DLI was not administered but MRD monitored; only in case of MRD positivity at 2 or 4 months additional low dose DLI was given. ResultsOf the 65 patients, 49 received standard dose DLI at 6 months after alloSCT (75%), either as a first dose at 6 months (40%), or as a second DLI after a low dose DLI at 3-4 months after alloSCT (35%). Reasons for not receiving standard dose DLI were NRM (5%), GVHD (9%), relapse (9%) and donor-related (2%). Of the 22 poor risk patients with a sensitive MRD marker, 15 received the first DLI at 6 months; 6 received both low dose DLI and 6 month DLI because of MRD positivity at 2 or 4 months after alloSCT; one patient did not receive prophylactic DLI because of systemic relapse at day 105. With a median follow up of 400 days (range 183-814), 12 patients developed systemic relapse. Most relapses (67%) occurred very early after transplant (median 110 days, range 63 to 165 days), before low dose DLI could be effectively given. These early relapses occurred significantly more in patients >= 65 years (88%) than <65 years (p=0.01 Fisher's exact). Overall survival at 1 year was 95% (95% CI 89-100%) in patients <65 (n=42), significantly higher than the 68% (95% CI 49-95%) in patients >=65 (n=23) (p=0.01). Relapse rate at 1 year was 5% (95% CI 1-15%) in patients <65, significantly lower than the 37% (95% CI 25-58%) in patients >=65 (p=0.001). Grade 2-4 acute and chronic GVHD incidence at 1 year was low (6% (95% CI 2-14%) and 11% (2.5-25%), respectively). Survival at 1 year was similar (p=0.35) in poor risk patients without MRD marker (80%, 95% CI 67-96%), poor risk with MRD marker (95%, 95% CI 87-100%) and intermediate risk (86%, 95% CI 63-100%). For these groups relapse risk was also similar: 18% (95% CI 7-33%), 16% (95% CI 3-36%) and 11% (95% CI 5-41%), respectively. ConclusionsThis study is the first to demonstrate feasibility of prophylactic DLI after PTCy-alloSCT with a low associated risk of GVHD. The observed low incidence of relapse at 1 year after transplantation (5%) of patients aged <65 years appears to be substantially less than the reported risk without pre-planned DLI (20-30%). Although the value of early DLI administration (around 3-4 months) is still unclear, standard dose DLI administration at 6 months appears feasible in intermediate risk patients and poor risk patients with sensitive MRD markers. Early relapses after alloSCT, at a time point before early DLI could be effective, caused the inferior survival of patients aged >= 65 years. The results of this study can serve as a reference for designing future prophylactic cellular interventions in the PTCy-alloSCT setting. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Time-Sequential Change of the Predictive Power of Peripheral Blood WT1mRNA Levels after Allogeneic Stem Cell Transplantation for Myeloid Neoplasm Relapse and Development of a Dynamic Relapse Prediction Model

Introduction:Wilms tumor 1 messenger RNA (WT1mRNA) is detected in patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS), and is reportedly a useful minimal residual disease (MRD) marker. Allogeneic stem cell transplantation (allo-SCT) is the established cellular immunotherapy with a graft-versus-leukemia (GVL) effect and eliminates residual leukemia cells via the alloimmune response. The GVL effect is generally considered to occur after immune reconstruction. Therefore, the predictive power of WT1mRNA as an MRD marker for relapse may differ between the early and late periods after allo-SCT because the GVL effect is not expected in the early period without enough immune reconstruction. However, no studies have reported whether the predictive power of WT1mRNA for relapse changes in a time-sequential manner after allo-SCT. Hence, we investigated the relationship between WT1mRNA as a time-dependent variable and days after allo-SCT for AML/MDS relapse using a dynamic landmarking approach, and developed a dynamic relapse prediction model using the WT1mRNA level and measurement timepoint after allo-SCT. Methods: We retrospectively analyzed AML and MDS patients who received allo-SCT at Osaka Metropolitan University Hospital, and whose WT1mRNA levels were measured at least once from January 2008 to April 2021. WT1mRNA levels in peripheral blood were measured using an "Otsuka" WT1mRNA assay kit (Otsuka Pharmaceutical Co., Ltd.). Relapse was defined as hematological relapse or salvage chemotherapy intervention and/or donor lymphocyte infusion. To evaluate time-sequential changes in the predictive power of WT1mRNA for relapse and to develop a dynamic relapse prediction model, dynamic landmarking analysis was performed, which was reported by Hans C. van Houwelingen et al. The probabilities of the 1 year cumulative incidence of relapse (CIR) post-landmark timepoint were estimated with the Kaplan-Meier method. The Cox proportional hazard regression model was used to calculate the time-sequential hazard ratio for 1 year CIR not only post-landmark but also post-any timepoints after allo-SCT, and to develop a dynamic relapse prediction model. p < 0.05 was considered significant. Results: We analyzed 265 patients (AML: 197 and MDS: 68) and 2,539 WT1mRNA tests. Median patient age was 46 years, 55% of patients achieved complete remission at the time of allo-SCT, and the 2 year relapse-free survival rate was 46%. First, patients were divided into two groups, namely, those with WT1mRNA levels higher and lower than 200 copies/μg RNA, which is a previously reported cutoff value. Figure 1 shows a summary plot of the 1 year CIR of the two groups post-landmark timepoint. The 1 year CIR decreased over time after allo-SCT in the lower WT1mRNA group but not in the higher WT1mRNA group. The difference in 1 year CIR between the two groups increased over time after allo-SCT. Moreover, the hazard ratio of log WT1mRNA levels for 1 year CIR post landmark timepoints after allo SCT increased over time, and there was a significant interaction between WT1mRNA levels and landmark time (p < 0.001). These findings indicate that the predictive power of WT1mRNA levels for relapse increases over time after allo-SCT. Second, we developed a dynamic relapse prediction model that can predict the 1 year CIR post-any timepoint after allo-SCT based on individual post-transplant WT1mRNA levels and measurement timepoints. Figure 2 shows a time series of predictive values for 1 year relapse post-any timepoints derived from this prediction model, which assumed that WT1mRNA levels remain constant over time after allo-SCT. Conclusions: We demonstrated that the predictive power of peripheral blood WT1mRNA for relapse increases after allo-SCT over time. This finding implies that MRD in the early phase after allo-SCT is more likely to disappear owing to the GVL effect after immune reconstruction compared to one in the late phase. Transplant clinicians should pay attention to the difference in predictive power for relapse depending on the period when they observe elevated WT1mRNA levels. Dynamic landmark analysis also enabled prediction of continuous 1 year CIR post-any timepoint after allo-SCT by inputting the individual WT1mRNA level and measurement timepoint. Dynamic relapse prediction will offer useful information for clinical decision making. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Significance of Gene Diagnosis in Acute Myeloid Leukemia with the Emergence of New Molecular Target Drug Treatment

Acute myeloid leukemia (AML) is a heterogeneous hematopoietic malignancy accompanied by impaired differentiation and autonomous proliferation of hematopoietic stem cells. Standard induction therapy results in first complete remission among 70% of patients with AML; however, approximately half of these patients relapse and become refractory. Allogeneic hematopoietic cell transplantation is a useful treatment for relapsed and refractory cases. However, transplantation-related mortality is approximately 20%, which is not a low value, and quality of life after transplantation decreases. Therefore, there is a need to stratify the prognosis of each patient and implement this treatment appropriately. Owing to recent advances in genome analysis technology, many gene mutations involved in onset and recurrence of AML have been discovered. These abnormalities and mutations not only have clinical application as prognostic factors and minimal residual disease markers, but they may also contribute to novel molecular targeted drug development. Many new drugs such as first-generation FMS-like tyrosine kinase 3 (FLT3), isocitrate dehydrogenase 1 and 2 (IDH1/2), and B cell lymphoma 2 (BCL2) inhibitors have been developed in the West. In addition, the second-generation FLT3 inhibitors gilteritinib and quizartinib were developed in Japan, and treatment outcomes for patients with AML have improved. However, there is still a large disparity in drug availability between the West, and Japan. As a result, treatment guidelines in the West cannot be applied in the clinical setting in Japan. In this study, we assessed the molecular target drug treatment by gene diagnosis for treatment of AML patients.

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

CtHPVDNA and Recurrence Risk in MC1675, a Secondary Analysis of a Phase III Evaluation of De-Escalated Adjuvant Radiation Therapy (DART) vs. Standard Adjuvant Treatment for HPV Associated Oropharyngeal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> We previously reported the results of a phase III clinical trial (MC1675) evaluating 30-36 Gy of adjuvant radiation therapy (RT) with weekly docetaxel (DART) vs standard of care (SOC) adjuvant (chemo)RT. We analyzed prospectively collected patient plasma specimens for circulating tumor tissue modified viral (TTMV)-HPV DNA as a marker of molecular residual disease (MRD) and its association with outcomes. <h3>Materials/Methods</h3> The DART regimen consists of transoral surgery (TOS) & neck dissection for a margin negative resection. Patients (pts) with intermediate risk factors received 30 Gy/1.5 Gy b.i.d. + docetaxel 15 mg/m² days 1 & 8, while pts with extranodal extension (ENE) received a simultaneous boost to 36 Gy/1.8 Gy b.i.d. to ENE+ nodal levels. Pts randomized to SOC received 60 Gy +/- cisplatin. Pts could optionally consent to plasma collection prior to surgery, post operatively, and 3 months after completion of RT. 2mL samples were de-identified and analyzed for TTMV-HPV DNA for HPV subtypes using a commercial test in a blinded fashion. A TTMV Score of >/= 5 normalized TTMV-HPV DNA fragments (frgs)/mL plasma was prespecified as MRD. Descriptive rates are reported along with Kaplan Meier (KM) estimates for progression free survival (PFS) by traditional risk factors and TTMV-HPV DNA. KM estimates were planned for patients treated per protocol. <h3>Results</h3> Of the 194 patients (DART: 130, SOC: 64), 150 had plasma available for analysis at any timepoint. Of 44 pts with pre-surgery plasma available, 37 (84%) had detectable TTMV-HPV DNA, with a median value of 250 frgs/mL (range 5-31092). Post-op, 137 pts had plasma available (median 21 days post-op), of which 16 (11%) had detectable post op TTMV-HPV DNA, median 10 frgs/mL. Three months after completion of RT, 114 pts had plasma available, of which 8 pts (7%) had detectable TTMV-HPV DNA median 43 frgs/mL. At 18 months, PFS was 73.1% for patients with post-op detectable MRD compared to 95.8% of patients with no MRD (p<0.01). Similarly, MRD at 3 months post treatment was associated with a PFS of only 25% at 18 months compared to 97.2% PFS in patients without MRD (p<0.0001). For pts receiving DART with ENE and pN1 disease, 18-month PFS was 66.7% in the setting of MRD compared to 88.8% for no MRD (p=0.08). <h3>Conclusion</h3> This secondary analysis of MC1675 validates post-op detectable TTMV-HPV DNA as a risk factor for recurrence and demonstrates 3-month post treatment TTMV-HPV DNA as an additional highly significant MRD timepoint identifying at least 50% of all recurrences. Assay standardization is paramount to future studies as well as pre-op collection on all patients. For patients with clinical risk factors such as ENE, our data support the hypothesis that post-op TTMV-HPV DNA could aid in patient selection for de-escalation.

S167: PREDICTION OF RELAPSE AFTER ALLOGENEIC STEM CELL TRANSPLANTATION USING INDIVIDUALIZED MEASURABLE RESIDUAL DISEASE MARKERS; THE PROSPECTIVE NORDIC STUDY NMDSG14B

Background: One third of patients with myelodysplastic syndrome (MDS) relapse after allogeneic stem cell transplantation (HCT). Early detection of impending relapse would enable pre-emptive treatment and potentially reduce relapse risk but is limited by the lack of sensitive markers for measurable residual disease (MRD). We developed a pipeline where patient-specific mutations, as determined by a myeloid next generation sequencing (NGS) panel are tracked using digital droplet PCR (ddPCR). Aims: To evaluate if personalized MRD detection by ddPCR can predict clinical relapse earlier than conventional methods. Methods: The prospective study (NCT02872662) enrolled patients with MDS, MDS/MPN or MDS-AML with < 30% marrow blasts undergoing HCT. Patients were included before HCT, and serial bone marrow (BM) samples were collected every third month post-HCT for 2 years. Peripheral blood (PB) samples were collected monthly. MRD results were not available for the treating physician. Results: We screened 286 pts between 2016 and 2020, whereof 20 were excluded mainly due to lack of genetic aberration or no HCT performed. 266 pts were included from 12 HCT centers. Median age was 64 (18-78) years and 59% were male. Myeloid panel NGS screening identified a median of 2 (0-9) mutations. The most common mutations were TET2 (n=85), ASXL1 (n=73) and SRSF2 (n=59). Median time of follow up was 886 (4-1934) days. Sixty pts relapsed after a median of 189 (53-1281) days and 46 died due to non-relapse mortality after a median of 121 (4-1036) days. Remaining pts (n=160) were in continuous complete remission (CCR) after a median follow-up of 1053 (479-1934) days. Estimated 1 and 2y overall survival was 79%, and 71%, respectively, while estimated 1 and 2y relapse-free survival (RFS) was 75% and 66%, respectively. MRD data was missing in 46 pts; no post-HCT samples available (n=15), no mutation detected (n=14) and difficulties to design ddPCR primers (n=11). 221 pts were available for MRD analysis with a median number of 4 (0-13) and 5 (0-23) samples from BM and PB, respectively. Of 53 clinical relapses with MRD results available, 42 were preceded by pos MRD (>0.1%) with a median of 70 (range 20-425) days between first pos MRD and clinical relapse. For the 11 remaining pts, 8 were inadequately sampled with a median time of 189 (82-397) days between last sampling and clinical relapse. One patient had an extramedullary relapse only. Of 31 pts who died without relapse, 19 were consistently MRD neg, while 5 were borderline positive (MRD > 0.1% and <0.5%) during the first 100 days but negative thereafter. Four MRD+ patients died without clinical relapse. Three pts were initially MRD+ but turned negative, all of which had chronic GVHD (cGVHD). Of 136 CCR patients, 94 were consistently MRD neg; 26 were borderline pos (MRD > 0.1% and <0.5%) during the first 100 days followed by neg samples; 16 were MRD positive (either > 0.5% during the first 100d or > 0.1% after 100d) of which 10 had a transition from pos to neg samples (all had cGVHD); one patient was treated for a molecular relapse detected by clinical routine method (FISH) and five patients were MRD positive at time of last follow-up. MRD used as a time-dependent co-variate was negatively associated with RFS (HR 7.1, p<0.01). Estimated cumulative incidence of relapse and non-relapse mortality 2y after pos MRD was 60% and 7% respectively (see figure). Image:Summary/Conclusion: We report the development of a highly functional personalized MRD pipeline based on patient-specific mutations showing a high sensitivity to predict relapse and relapse-free survival.

P509: CLONAL HEMATOPOIESIS-ASSOCIATED MUTATIONS AS MEASURABLE RESIDUAL DISEASE MARKERS IN ACUTE MYELOID LEUKEMIA PATIENTS FOLLOWING ALLOGENEIC STEM CELL TRANSPLANTATION

Background: Clonal hematopoiesis (CH)-associated mutations (mut) are frequent in acute myeloid leukemia (AML), appear early in leukemogenesis, and often persist in remission after chemotherapy. Following allogeneic hematopoietic stem cell transplantation (HSCT), which replaces the patients’ hematopoiesis, CH mut may present useful measurable residual disease (MRD) markers. Aims: To evaluate patient specific CH-associated mut as MRD markers in AML patients (pts) after allogeneic HSCT. Methods: We analyzed 31 AML pts with CH-associated mut present at diagnosis (DNMT3A: n=17; SRSF2: n=9; IDH2: n=7; ASXL1: n=4; TET2: n=2, and JAK2: n=1), 23 pts had 1, 7 had 2, and 1 patient had 3 CH mut. All received a myeloablative (36%), reduced-intensity (48%), or non-myeloablative (16%) HSCT (median age 58, range 32-72 years). 84% were transplanted in complete remission (CR) or CR with incomplete recovery (CRi). European Leukemia Net (ELN) risk was 23% favorable, 37% intermediate, and 40% adverse. Mut-specific digital droplet PCR assays were developed using a competitive probe-approach. MRDpos was defined as variant allele frequency (VAF) ≥2% for ASXL1 & ≥0.05% for all other analyzed mut. 209 samples with a median of 6 (range 1-13) blood or bone marrow samples per patient were available after HSCT with a median of 1.2 years follow-up time for pts alive. Results: Prior to HSCT, 89% of pts remained CH-associated mut positive in CR/CRi. 11 pts relapsed after HSCT (35%), all with the same CH-associated mut present at diagnosis (median VAF at relapse 15.6, range 0.2-41.2%). Of those, 6 pts had at least 1 MRD sample available prior to relapse. In 5 pts, impeding relapse was predicted by a CH-associated mut MRD conversion with a median VAF of 0.27 (range 0.06-1.0)% at a median of 103 (range 14-199) days prior to relapse. The lead time was longest for a DNMT3A mut patient (199 days) & shortest for a SRSF2 mut patient (14 days). For the patient relapsing without prior CH MRD positivity, the last available sample was taken 169 days before relapse & was CH MRDneg. 20 pts retained remission during follow-up. Of those, 17 pts remained CH MRDneg in all samples (median samples per analyzed mutation 6, range 1-13). 2 pts had 2 MRDpos samples directly after HSCT but became MRDneg in subsequent samples. 1 patient received Enasidenib maintenance after HSCT with fluctuating CH-MRD values after HSCT (SRSF2 & IDH2, VAFs <0.05-0.34% & <0.05-0.14%, respectively). Of the pts with MRD samples within the first year after HSCT available, pts with at least 1 MRDpos sample after HSCT had a significantly higher cumulative incidence of relapse (CIR, P=.008, Figure 1A) & shorter relapse-free survival (RFS, P=.02, Figure 1B). 8 pts had concurrent NPM1 mut (n=4) or RUNX1 mut (n=4), which showed concordant MRD results in 7 pts (4 remained MRDneg, 3 concurrently converted MRDpos). 1 patient suffered a NPM1 MRDneg relapse which was predicted by 2 re-detected CH-associated mut (DNMT3A mut & IDH2 mut, 112 & 199 days prior to relapse, respectively, Figure 1C). Image:Summary/Conclusion: Prior to HSCT most CH-associated mut remain detectable in pts in CR/CRi. However, pts with at least one CH MRDpos sample following allogeneic HSCT had higher CIR & shorter RFS. All relapsing pts were positive for the same CH-associated mut present at diagnosis. 5 of 6 showed increasing VAFs prior to hematologic relapse & the majority of pts retaining remission remained CH MRDneg. While CH-associated mut in chemotherapy treated AML pts have limited MRD value, these mut are feasible MRD markers after HSCT & may inform relapse preventing therapy decisions.

MEDB-74. Serial assessment of measurable residual disease in medulloblastoma liquid biopsies

Nearly one-third of children with medulloblastoma, a malignant embryonal tumor of the cerebellum, succumb to their disease. Conventional response monitoring by imaging and cerebrospinal fluid (CSF) cytology remains challenging and a marker for measurable residual disease (MRD) is lacking. Here, we show the clinical utility of CSF-derived cell-free DNA (cfDNA) as a biomarker of MRD in serial samples collected from children with medulloblastoma (123 patients, 476 samples) enrolled on a prospective trial. Using low-coverage whole-genome sequencing, tumor-associated copy-number variations (CNVs) in CSF-derived cfDNA are investigated as an MRD surrogate. MRD is detected at baseline in 85% and 54% of patients with metastatic and localized disease, respectively. The number of MRD-positive patients decline with therapy, yet those with persistent MRD have significantly higher risk of progression. Importantly, MRD detection precedes radiographic progression in half who relapse. Our findings advocate for the prospective assessment of CSF-derived liquid biopsies in future trials for medulloblastoma.

The Clinical Applications of Liquid Biopsies in Pediatric Brain Tumors: A Systematic Literature Review.

Simple SummaryBrain tumors are the most common solid cancer in children and are traditionally diagnosed via a tissue biopsy or resection. Liquid biopsy offers the possibility to characterize brain tumors based on their circulating DNA in blood, cerebrospinal fluid or even urine. Moreover, disease progress can be monitored accurately and sometimes even detected before radiographic progression. More trials are needed to standardize the use of liquid biopsy in pediatric brain tumors.Background: Pediatric brain tumors are the most common solid tumor in children. Traditionally, tumor diagnosis and molecular analysis were carried out on tumor tissue harvested either via biopsy or resection. However, liquid biopsy allows analysis of circulating tumor DNA in corporeal fluids such as cerebrospinal fluid or blood. Methods: We performed a systematic review in Pubmed and Embase regarding the role of liquid biopsy in pediatric brain tumors. Results: Nine studies with a total of 570 patients were included. The preferred corporeal fluid for analysis with a relatively high yield of ct-DNA was cerebrospinal fluid (CSF). For high-grade glioma, liquid biopsy can successfully characterize H3K27mutations and predict tumor progression before it is radiographically detected. Moreover, liquid biopsy has the potential to distinguish between pseudo-progression and actual progression. In medulloblastoma, ct-DNA in the CSF can be used as a surrogate marker of measurable residual disease and correlates with response to therapy and progression of the tumor up to three months before radiographic detection. Conclusion: Liquid biopsy is primarily useful in high-grade pediatric brain tumors such as diffuse midline glioma or medulloblastoma. Disease detection and monitoring is feasible for both tumor entities. More trials to standardize its use for pediatric brain tumors are necessary.

Allelic complexity of KMT2A partial tandem duplications in acute myeloid leukemia and myelodysplastic syndromes

AbstractKMT2A partial tandem duplication (KMT2A-PTD) is an adverse risk factor in acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS), a potential therapeutic target, and an attractive marker of measurable residual disease. High initial KMT2A-PTD RNA levels have been linked to poor prognosis, but mechanisms regulating KMT2A-PTD expression are not well understood. Although KMT2A-PTD has been reported to affect only a single allele, it has been theorized but not proven that genomic gains of a monoallelic KMT2A-PTD may occur, thereby potentially driving high expression and disease progression. In this study, we identified 94 patients with KMT2A-PTDs using targeted DNA next-generation sequencing (NGS) and found that 16% (15/94) had complex secondary events, including copy-neutral loss of heterozygosity and selective gain involving the KMT2A-PTD allele. High copy numbers indicating complexity were significantly enriched in AML vs MDS and correlated with higher RNA expression. Moreover, in serial samples, complexity was associated with relapse and secondary transformation. Taken together, we provide approaches to integrate quantitative and allelic assessment of KMT2A-PTDs into targeted DNA NGS and demonstrate that secondary genetic events occur in KMT2A-PTD by multiple mechanisms that may be linked to myeloid disease progression by driving increased expression from the affected allele.

MP54-01 DISCORDANCE BETWEEN CLINICAL AND PATHOLOGIC CARCINOMA IN SITU FOR TURBT AND RADICAL CYSTECTOMY IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER: IMPLICATIONS FOR BCG UNRESPONSIVE CLINICAL TRIAL DESIGN AND INTERPRETATION

You have accessJournal of UrologyCME1 May 2022MP54-01 DISCORDANCE BETWEEN CLINICAL AND PATHOLOGIC CARCINOMA IN SITU FOR TURBT AND RADICAL CYSTECTOMY IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER: IMPLICATIONS FOR BCG UNRESPONSIVE CLINICAL TRIAL DESIGN AND INTERPRETATION Manuel R. de Jesus Escano, Carissa Chu, Song Jiang, Wesley Yip, Nima Almassi, Peter Reisz, Andrew Lenis, Nicole Benfante, Eugene Cha, Timothy F Donahue, Guido Dalbagni, Alvin Goh, Bernard Bochner, and Eugene Pietzak Manuel R. de Jesus EscanoManuel R. de Jesus Escano More articles by this author , Carissa ChuCarissa Chu More articles by this author , Song JiangSong Jiang More articles by this author , Wesley YipWesley Yip More articles by this author , Nima AlmassiNima Almassi More articles by this author , Peter ReiszPeter Reisz More articles by this author , Andrew LenisAndrew Lenis More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Eugene ChaEugene Cha More articles by this author , Timothy F DonahueTimothy F Donahue More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , Alvin GohAlvin Goh More articles by this author , Bernard BochnerBernard Bochner More articles by this author , and Eugene PietzakEugene Pietzak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002633.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The FDA recommends non-muscle invasive bladder cancer (NMIBC) trials stratify patients into two groups: carcinoma in situ (CIS) with or without papillary disease (CIS±Ta/T1) and papillary only disease (Ta/T1). Complete response rate is used as indicator of drug efficacy for approval in Phase II BCG unresponsive trials, yet limited data supports this classification. Moreover, effects of TURBT on response rate is not well stablished in NMIBC trials. To address this, we analyzed the concordance of CIS between TURBT and corresponding radical cystectomy (RC) specimens in NMIBC patients. METHODS: Patients treated with immediate RC at our center for high grade NMIBC between 2005-2015. Pre-RC TURBT/EUA and RC were performed at our center for study inclusion. Enhanced cystoscopy techniques during TURBTs were recorded. BCG unresponsive was defined using FDA criteria. BCG relapsing was defined as prior BCG treatment, but not meeting BCG unresponsive criteria. Clinical CIS (cCIS) was defined as histologic CIS in TURBT specimen, and pathologic CIS (pCIS) as histologic CIS in RC specimen. RESULTS: Of 610, 302 (49%) were BCG naïve and 308 (51%) had prior BCG. 358 (59%) had positive cCIS, 419 (69%) had positive pCIS, and 486 (80%) had any CIS (either+cCIS or +pCIS). In those with +cCIS, 289 (81%) had residual pathologic CIS (+cCIS/+pCIS), while eradication of CIS (+cCIS/−pCIS) was seen in 69 (19%). For those without cCIS at TURBT, concordance with RC (−cCIS/−pCIS) was seen in 124 (49%), while occult pathologic CIS (−cCIS/+pCIS) was detected in 128 (51%). In those BCG unresponsive (n=99), eradication of CIS by TURBT was seen in 16% (8/51) who would have been included in CIS±Ta/T1 cohorts, while occult pathologic CIS was seen in 52% (25/48). A similar frequency of CIS eradication (18%) and occult pathologic CIS (46%) was seen in the BCG relapsing subgroup. CONCLUSIONS: We report the potential utility of CIS as a marker of residual disease. Based on our findings, >15% of NMIBC patients in single-arm FDA registration trials might experience complete responses from the effects of TURBT alone, raising concerns about the interpretation of these trials. Furthermore, occult pathologic CIS was found in half of NMIBC patients who would incorrectly be placed into the papillary Ta/T1 only cohort of current NMIBC clinical trial stratification schema. Better measures of residual CIS after TURBT are needed to improve patient stratification and drug efficacy evaluations in NMIBC trials. Source of Funding: SKC for Prostate and Urologic Cancers, NIH/NCI to MSKCC through CCSG award #P30 CA008748, MJ and HRK CMO, MSKCC SPORE in BC P50-CA221745, MSKCC SPORE CE A., MSKCC Dept. of Surgery FR A., Bochner-Fleisher Scholars in BC Award, NIH/NCATS #UL1-TR-002384, NIH/NCI K12 Paul Calabresi CD A. for C Onc (K12 CA184746), Wofchuck Family A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e926 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Manuel R. de Jesus Escano More articles by this author Carissa Chu More articles by this author Song Jiang More articles by this author Wesley Yip More articles by this author Nima Almassi More articles by this author Peter Reisz More articles by this author Andrew Lenis More articles by this author Nicole Benfante More articles by this author Eugene Cha More articles by this author Timothy F Donahue More articles by this author Guido Dalbagni More articles by this author Alvin Goh More articles by this author Bernard Bochner More articles by this author Eugene Pietzak More articles by this author Expand All Advertisement PDF DownloadLoading ...

Optical Genome Mapping as a Diagnostic Tool in Pediatric Acute Myeloid Leukemia.

Simple SummaryTreatment of pediatric acute myeloid leukemia (AML) is stratified according to multiple recurrent genetic aberrations, which require for detection of different diagnostic methods such as karyotyping and fluorescence in situ hybridization (FISH). The aim of this study was to analyze whether optical genome mapping (OGM), as a new all-in-one methodological approach, can identify all stratification-relevant genetic aberrations that were described by karyotyping. Therefore, frozen bone marrow and blood cells from 24 pediatric patients with AML, bi-lineage leukemia, and mixed-phenotype acute leukemia collected at diagnosis were analyzed by OGM. The results of OGM were compared with routine diagnostic results from karyotyping and FISH. We show that OGM has much potential to address limitations of cytogenetics and even identify new structural aberrations that can be useful for monitoring minimal residual disease (MRD) in patients without an MRD marker.Pediatric AML is characterized by numerous genetic aberrations (chromosomal translocations, deletions, insertions) impacting its classification for risk of treatment failure. Aberrations are described by classical cytogenetic procedures (karyotyping, FISH), which harbor limitations (low resolution, need for cell cultivation, cost-intensiveness, experienced staff required). Optical Genome Mapping (OGM) is an emerging chip-based DNA technique combining high resolution (~500 bp) with a relatively short turnaround time. Twenty-four pediatric patients with AML, bi-lineage leukemia, and mixed-phenotype acute leukemia were analyzed by OGM, and the results were compared with cytogenetics. Results were discrepant in 17/24 (70%) cases, including 32 previously unknown alterations called by OGM only. One newly detected deletion and two translocations were validated by primer walking, breakpoint-spanning PCR, and DNA sequencing. As an added benefit, in two cases, OGM identified a new minimal residual disease (MRD) marker. Comparing impact on risk stratification in de novo AML, 19/20 (95%) cases had concordant results while only OGM unraveled another high-risk aberration. Thus, OGM considerably expands the methodological spectrum to optimize the diagnosis of pediatric AML via the identification of new aberrations. Results will contribute to a better understanding of leukemogenesis in pediatric AML. In addition, aberrations identified by OGM may provide markers for MRD monitoring.

Impact of IDH1 and IDH2 mutation detection at diagnosis and in remission in patients with AML receiving allogeneic transplantation

AbstractSomatic mutations in the isocitrate dehydrogenase 1 and 2 genes (IDH1 and IDH2) are common in acute myeloid leukemia (AML). The prognostic impact of the presence of IDH mutations may be influenced by the comutational status, the specific location of the mutation (ie, IDH1 R132, IDH2 R140, and IDH2 R172) at diagnosis, and the dynamics of the mutation burden during disease course. Even though many patients with IDH-mutated AML are consolidated by hematopoietic stem cell transplantation (HSCT), the underlying biology and prognostic consequences remain largely unknown. Here, we present a large analysis of 292 patients with AML who received HSCT in complete remission (CR) or CR with incomplete peripheral recovery (CRi), in which we assessed the IDH mutation status at diagnosis and HSCT as a potential marker for measurable residual disease (MRD). About a quarter of all patients were IDH-mutated at diagnosis. The diagnostic presence of IDH mutations in AML did not have a significant prognostic impact when consolidated with HSCT. However, IDH1 R132 and IDH2 R172 MRD positivity in remission at HSCT associated with an increased risk of relapse, while IDH2 R140 mutations did not. The IDH2 R140 variant allele frequency (VAF) at diagnosis was higher, clustering around 50%, and the mutation clearance at HSCT in morphologic remission was much lower compared with IDH1 R132 and IDH2 R172. In our cohort, IDH2 R140 mutations behaved more like a clonal hematopoiesis-related aberration, while IDH1 R132 and IDH2 R172 harbored AML disease-specific features.

Risk Stratification, Measurable Residual Disease, and Outcomes of AML Patients with a Trisomy 8 Undergoing Allogeneic Hematopoietic Stem Cell Transplantation.

Simple SummaryTrisomy 8 is the most common numerical chromosome aberration in acute myeloid leukemia (AML). Although this AML type is often consolidated applying allogeneic hematopoietic stem cell transplantations (HSCT), detailed analyses of outcomes after HSCT are lacking. The purpose of this manuscript is to analyze biological and clinical features of patients with this cytogenetic aberration in the context of significant risk factors, including the ELN2017 risk stratification and measurable residual disease markers at HSCT. Our data provides evidence on the clinical disease courses and may aid in informed decisions on treatment and outcome prediction of trisomy 8 AML patients undergoing allogeneic HSCT.Background: For most patients with acute myeloid leukemia (AML) harboring a trisomy 8 an allogeneic hematopoietic stem cell transplantation (HSCT) is a suitable and recommended consolidation therapy. However, comparative outcome analyses between patients with and without trisomy 8 undergoing allogeneic HSCT have not been performed so far. Methods: We retrospectively analyzed clinical features, outcomes, and measurable residual disease (MRD) of 659 AML (12%, n = 81, with a trisomy 8) patients subjected to allogeneic HSCT as a consolidation therapy. Results: The presence of a trisomy 8 associated with a trend for higher age at diagnosis, AML of secondary origin, lower white blood cell counts at diagnosis, worse ELN2017 genetic risk, wild-type NPM1, and mutated IDH1/2 and JAK2. Outcomes after allogeneic HSCT in the entire cohort did not differ between patients with a sole trisomy 8, trisomy 8 with additional cytogenetic aberrations or without a trisomy 8. A trisomy 8 did not affect outcomes within the three ELN2017 risk groups. In accordance with findings in unselected patient cohorts, persistent MRD at allogeneic HSCT in patients with a trisomy 8 identified individuals with a higher risk of relapse following allogeneic HSCT. Conclusions: Outcomes of trisomy 8 patients after allogeneic HSCT did not compare unfavorably to that of other AML patients following allogeneic HSCT. Rather than the presence or absence of a trisomy 8, additional genetic aberrations and MRD at HSCT define outcome differences and aid in informed treatment decisions.

BIOM-36. SERIAL ASSESSMENT OF MEASURABLE RESIDUAL DISEASE IN MEDULLOBLASTOMA LIQUID BIOPSIES

Abstract Medulloblastoma is the most common malignant brain tumor in children. Despite the use of contemporary multi-modal therapy, up to one-third of patients will succumb to disease progression. Conventional response monitoring is based on magnetic resonance imaging and cerebrospinal fluid (CSF) cytology and a marker for measurable residual disease (MRD) is lacking. In this study, we show the clinical utility of profiling CSF-derived cell-free DNA (cfDNA) as a biomarker of MRD based on a sizable cohort of children with medulloblastoma enrolled on a prospective, multi-center, risk-adapted trial (SJMB03; NCT00085202). A total of 476 CSF samples were serially collected from 123 patients by lumbar puncture at post-operative baseline, during therapy, and at regular surveillance after completion of therapy. Using low-coverage whole-genome sequencing (lcWGS), tumor-associated copy-number alterations in CSF-derived cfDNA were investigated as an MRD surrogate for correlation with clinical features and outcomes. MRD was detected in post-operative baseline CSF samples for 85% and 54% of patients with metastatic and localized disease, respectively. The number of MRD-positive patients declined with therapy, yet those with persistent MRD detected at the end of therapy (20 of 68 CSFs at this timepoint) had significantly higher risk of disease progression (hazard ratio 8.94, 95%CI 4.10-19.49; log-rank p&amp;lt; 0.0001). Importantly, MRD-positivity from routine surveillance samples often preceded radiographic progression by more than 3 months. Comparative analyses of copy-number variations obtained from serial CSF samples enabled identification of relapse-specific alterations and early detection of relapse-dominant clones. Overall, our findings advocate for the routine incorporation of CSF-derived liquid biopsies in future medulloblastoma trials.

Clinical Outcomes of Adults and Young Adults (AYA) with Acute Lymphoblastic Leukemia (ALL): A Multicenter Analysis of Pediatric-Inspired Protocol (MASPORE) Vs Hyper-CVAD in Singapore

Introduction:In acute lymphoblastic leukemia (ALL) adolescents and young adults (AYA), there are benefits when using pediatric over adult treatment regimes. There is improved overall survival (OS), progression free survival (PFS) and reduced need for hematopoietic stem cell transplantation; all while having an acceptable toxicity profile. Yet, studies supporting this were largely performed in a western population (e.g., United Kingdom and United States) and thus may have had limited representation of the Asian population. Whether these results are generalizable and applicable to an Asian population is in question. MASPORE, a locally designed pediatric regiment based on BFM regimen, which has been used successfully in Singapore and Malaysia's AYA cohort since 2007. MASPORE protocol utilized PCR-based minimal residual disease (MRD) marker to risk stratify patients according to disease severity and used a 3- or 4-drug induction regimen depending on intermediate or high-risk stratification (L-asparaginase, Vincristine, Dexamethasone +/- daunorubicin). In contrast HyperCVAD does not use MRD to stratify or guide management. In this retrospective study performed in Singapore, we aim to demonstrate that MASPORE is an effective treatment option for AYA ALL in Asian population.Methods:Patient registries (IRB approved) spanning from January 2005 to June 2021 from three tertiary hospitals in Singapore were reviewed. ALL patients who were AYA, defined as less than 40 years of age, treated during this time were included and analyzed. Patients were treated with either the pediatric protocol MASPORE or with the adult protocol HyperCVAD. Patients who are Philadelphia positive were excluded from the MASPORE arm up to 2020. Patients' demographics, functional status, risk profile, adverse events, as well as the hematological response and transplant status were collected and analyzed with Pearson chi-square test. Kaplan Meier curve analysis were performed for OS and PFS with SPSS software.Results:In this retrospective study, 116 patients were analyzed. Among these patients 29 (25%) received MASPORE and 87 (75%) received HyperCVAD. The median age was 23 (range 18-40) for MASPORE arm vs 28 years (range 15-40) for the HCVAD arm. median follow-up time was 4.5 vs 10.8 years. Both groups were similar in gender, race, ECOG status, and ALL risk status at diagnosis. Likewise, both arms did not have differences in starting hematological parameters: hemoglobin, total white blood cell count, platelet count, absolute neutrophil count, and bone marrow blast percentages. Median time from diagnosis to treatment was 3 and 4 days for MASPORE and HyperCVAD arms respectively. There were increased adverse rates for patients in the MASPORE arm. They had more (13.8 vs 0.0%, p < 0.001) of which 75% of the pancreatitis were CTCAE grade 3/4, avascular necrosis (13.8 vs 2.2%, p = 0.016), cerebral venous thrombosis (13.8 vs 1.1%, p = 0.004) and other thrombosis (27.6 vs 5.7%, p = 0.004). For the MASPORE and HyperCVAD arms there was one induction death, one from sepsis and the other from pneumonia . Both arms managed to achieve complete response (CR) with equivalent rates (82.5 vs 80.5%, p = 0.752). However, there was less relapsed or refractory disease in those treated with MASPORE (10.3 vs 44.8%, p < 0.001). The 5- OS was better in the MASPORE versus the HyperCVAD arm (4.4 vs 3.7 years; p = 0.049). Likewise, the 5-year PFS was superior in the MASPORE arm (4.2 vs 3.2 years, p = 0.034). Furthermore, a smaller proportion of patients required consolidative stem cell transplant (13.8 vs 49.4%, p < 0.001).Conclusion:The pediatric-inspired protocol MASPORE achieved similar CR rates with OS and PFS benefit, reduced relapse rates, and less need for consolidative stem cell transplant. MASPORE serves as a viable treatment option when treating AYA patients with ALL. Larger prospective studies are needed to further explore its use. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.