minimal residual disease in pediatric all; power and pitfalls · prof. giuseppe basso md pediatric...

Prof. Giuseppe Basso MD Pediatric Hemato-Oncology Division SDB Dept. University of Padua Italy [email protected]

Minimal Residual Disease in Pediatric ALL; Power and Pitfalls

Pediatric ALL a Success Story

IMPROVEMENT IN THERAPY RESULTS

BIOLOGICALLY DERIVED INFORMATION

• A well defined and profound diagnosHc approach

• Risk classificaHon obtained from biological factors

• Development of tailored therapies based on individual therapy response; MRD

• New therapeuHc approaches(BMT, biological drugs…)

MRD a long story

Background

PCR-based MRD measurement has prognostic implications in childhood

I-BFM-SG, Van Donghen JJ,….., Lancet 1998

I-BFM-SG ALL-MRD-Study: Update 2002, 5y-pEFS (fromw12) Outcome by MRD detection levels at w5 (tp 1) and w12 (tp 2)

MRD at tp. 1+2 neg.: 0.98, SE=.02 (N= 55, 1 event) MRD pos but < 10-3 at tp. 2: 0.76, SE=.06 (N= 55, 14 events) MRD at tp. 1+2 >=10-3: 0.16, SE=.08 (N= 19, 16 events)

years

p: 1-2: .0003; 1-3: .0001; 2-3: .0001 mrd

_upd

2.ka

m 0

2JA

N03

P

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 1 2 3 4 5 6 7 8 9 10 11

M.S. (ALL-BFM) 13.3.03

Basis for risk stratification in trial ALL-BFM 2000

Low risk group

Intermediate risk group

High risk group

Background

•  PCR-based MRD measurement has prognostic implications in childhood ALL (I-BFM-SG, Lancet 1998)

•  AIEOP-‐BFM-‐ALL 2000 trial demonstrated that PCR-‐MRD straHficaHon is feasible on a large scale (3184 paHents) and allows idenHficaHon of different paHent subgroups.

IBFM-‐SG, Conter V, Blood 2010

1348 61 6.0%(0.8) 7.2%(1.2)1647 266 21.0%(1.2) 22.3%(1.4)189 60 34.9%(3.8) 38.5%(5.0)

SRIRHR

N.pts N. rel. 5-yrs CI 7-yrs CI

p-value<0.001

Cum. Incidence

0.0

0.2

0.4

0.6

0.8

1.0

Years from diagnosis

0 1 2 3 4 5 6 7

Figure 1- panel b

Conter V et al, Blood; 2010

1348N. pts

81N. events

92.3%(0.9)5 yrs EFS

91.1%(1.2)7 yrs EFS

SR

p-value<0.001

1647

N. pts

288

N. events

77.6%(1.3)

5 yrs EFS

76%(1.4)

7 yrs EFS

MR

p-value<0.001189

N. pts

86

N. events

50.1%(4.1)

5 yrs EFS

46.6%(5.1)

7 yrs EFS

HRp-value<0.001

EFS

0.0

0.2

0.4

0.6

0.8

1.0

YEARS FROM DIAGNOSIS

0 1 2 3 4 5 6 7

Monitoring minimal residual disease (MRD) has become the standard of care in pediatric paIents with acute lymphocyIc leukemia (ALL) based on evidence that it is a strong prognos:c factor for pa:ent outcomes – pa:ents who test nega:ve for MRD have beCer outcomes than those who test posi:ve. However, MRD isn’t a panacea. There are sIll many unanswered quesIons about what MRD is able to tell us, and what it isn’t – especially in adult paIents with ALL. The use of MRD monitoring in adult pa:ents is much less prevalent due to a lack of clear evidence and inconsistencies among the labs that conduct the tests.

By Jill Sederstrom; Minimal Residual Disease: ALL It’s Cracked Up to Be?

In the United States, the most common method for detecIng MRD is flow cytometry: leukemia-‐associated immunophenotypes……. In Europe, the common approach is using polymerase chain reacIon (PCR) to screen and amplify a DNA in the immuglobulin gene or T-‐cell receptor to idenIfy a clone associated with leukemia. Each method has its own set of advantages and disadvantages. Flow cytometry, for instance, is less expensive, can oYen report quanItaIve results within a day, and has a larger evidence base (having been used in most U.S.-‐based trials).

By Jill Sederstrom

•  High sensiCvity and high specificity •  Fast

•  Cheap •  Easy in standardizaCon •  UClized rouCnely in the majority of paCents

•  QuanCficaCon of posiCve cells

The perfect MRD methodology

Coustan-Smith E and Campana D, 2013

EvoluHon in MRD Technologies

•  Molecular NGS applicaHon increase the ability in mulHclones idenHficaHon and quanHficaHon (standardizaHon on going..). False negaHve. Digital PCR and absolute quanHficaHon. •  FCM The number of anHgens simultaneously tested are increasing (sensiHvity and specificity are improving); quality reagents new generaHon instrumentaHons.

Background

•  PCR-based MRD measurement has prognostic implications in childhood ALL (I-BFM-SG, Lancet 1998)

•  AIEOP-BFM-ALL 2000 trial demonstrated that PCR-MRD stratification is feasible on a large scale and allows identification of different patient subgroups

•  Is it possible to further refine the use of MRD measurements for treatement of childhood ALL?

DIAGNOSIS

FRONT LINE TREATMENT

STOP THERAPY INDUCTION

FOLLOW UP INDUCTION

POTENTIAL TREATMENT DECISIONS BASED ON MRD

FOLLOW UP

RELAPSE

Clinical relevance of MRD•  Before therapy, as stratification tool

•  During therapy, to evaluate effectiveness and to choose the most appropriate therapeutic strategy (stratification)

•  ALL paIents who don’t have MRD at earlier points in their therapy tend to have the best prognosis,

•  At stop therapy, to choose the most appropriate therapeutic strategy

•  For this reason in the future the MRD technologies will improve there utilization

AIEOP-BFM LLA 2009

PEG-ASP data per 20 settimane

Prot. IB-ASP+ (con 4 x 2500 E PEG-L-ASP

Prot. IA‘ (con Pred e 2 dosi DNR nei giorni 8 and 15)

Prot. IA (con Pred e 4 dosi DNR nei giorni 8, 15, 22 e 29)

IBASP+

IAD IA

IA’

Prot. IAD (con Dexa e 4 dosi DNR nei giorni 8, 15, 22 e 29)

IACPM Prot. IACPM (con Pred, 4 dosi DNR e 1 dose CPM al giorno 10)

MR

Pazienti selezionati$

IB M IAD

IBASP+

IB

IA SCT DNX-FLA + SCT

II

II R2

T/non-HR

pB#/ non-HR

II SR

IB M

IA’

IA R1

§

IA

53 104 sett. 12 1

HR 1‘

II

22 31 43

HR 2‘

HR 3‘

20 10

III III

± pCRT * III HR

IACPM

RHR

LLA-T

pB-LLA#

± pCRT *

# o immunofenotipo non noto * pCRT 12 Gy se età ≥ 2 aa / in sottogruppi selezionati non

pCRT + 6x IT MTX / in pazienti con malattia SNC (SNC 3) tCRT con 12 Gy o 18 Gy (dose età-dipendente)

§ per eleggibilità alla randomizzazione vedi protocollo $ vedi protocollo

Day 15 Day 33-‐78

MRD as “surrogate” marker to assess heterogeneity in response to treatment

Szcepanski T et al, 2001 modified

DAY 15 TECHNICAL ADVANTAGES

•  Very early in vivo response to drugs (PDN, VCR, DN, L-‐ASP) •  OpHmal Hme point for evaluaHon of residual disease by flow

cytometry: •  -‐ Easy blast cells enumeraHon •  -‐ No regeneraHng B cells in BM (avoid bias in dot plots evaluaHon) •  Easy apoptoHc cells enumeraHon.

PDN 60 mg/mq die

DAUNO:30mg/mq

1 8 15 22 29 33

L-ASP 5UL/mq

MTX IT

VCR:1,5 mg/mq

RDXM 10 mg/mq die

PDN

BM BM

PDN 60 mg/mq die

DAUNO:30mg/mq

1 8 15 22 29 33

L-ASP 5UL/mq

MTX IT

VCR:1,5 mg/mq

RDXM 10 mg/mq die

PDN

BM BM

ARA-C:

75mg/mq/ die

36 43 50 57 64 78

CPM 1 gr./mq

MTX IT

BM BM

6-MP 60mg/mq/ die

ARA-C:

75mg/mq/ die

36 43 50 57 64 78

CPM 1 gr./mq

MTX IT

BM BM

6-MP 60mg/mq/ die

PBPB

PBPB PBPB

INDUCTION IA INDUCTION IB

AIEOP-BFM ALL 2009

Day 15 Day 33 Day 78

(A) Event-‐free survival (EFS) and (B) cumulaHve incidence of relapse in 815 paHents treated in the AIEOP-‐BFM-‐ALL 2000 trial, straHfied into three risk groups according to minimal residual disease on day 15

marrow as detected by flow cytometry.

Basso G et al. JCO 2009;27:5168-‐5174

©2009 by American Society of Clinical Oncology

Nature Reviews Clinical Oncology Volume 7, January 2010

While we do know that ALL pa:ents who don’t have MRD at earlier points in their therapy tend to have the best prognosis, researchers are sIll trying to determine the best way to treat paIents who appear to be in remission based on morphologic examinaIons but who sIll have MRD. Consensus about whether MRD can be used as an endpoint in clinical trials, or whether oncologists should be monitoring MRD to signal relapse, have yet to be reached.

By Jill Sederstrom

Open quesHon

MRD as “surrogate” marker to assess heterogeneity in response to treatment

?

Clinical relevance of MRD•  Before therapy, as stratification tool

•  During therapy, to evaluate effectiveness and to choose the most appropriate therapeutic strategies

•  Clinical utility of sequential MRD measurement in early phase of treatment

•  At stop therapy, to choose the most appropriate therapeutic strategy

•  For this reason in the future the MRD technologies will improve there utilization

In a retrospecCve study (AIEOP-‐BFM 2000), during posCnducCon treatment 110 paCents were categorized as negaCve, low posiCve (< 5 × 10-‐4), or high posiCve (≥ 5 × 10-‐4). PaCents with at least one low-‐posiCve or high-‐posiCve result were assigned to the corresponding subgroup. RESULTS: PaCents who tested during posCnducCon therapy high posiCve, low posiCve, or negaCve had significantly different cumulaCve incidences of leukemia relapse: 83.3%, 34.8%, and 8.6%, respecCvely (P < .001).

Cumulative incidence of relapse (Cum Inc Rel) in 110 children with acute lymphoblastic leukemia, according to the results of minimal residual disease during postinduction

treatment.

Maddalena Paganin et al. JCO 2014;32:3553-3558

©2014 by American Society of Clinical Oncology

... Two thirds of posiCve cases were idenCfied within 4 months aker inducCon-‐consolidaCon therapy, suggesCng that this Cme frame may be most suitable for cost-‐effecCve MRD monitoring, parCcularly in paCents who did not clear their disease at the end of consolidaCon. CONCLUSION: These findings provide further insights into the dynamic of MRD and the ongoing effort to define mrd relapse in childhood ALL.

DIAGNOSIS

FRONT LINE TREATMENT

STOP THERAPY

INDUCTION

FOLLOW UP

POTENTIAL TREATMENT DECISIONS BASED ON MRD

MRDDuring the follow up/ Stop Therapy

1.  The suspect cells are blast cells? identical to those found at diagnosis or have they changed?

2.  Is it a relapse or a secondary leukemia?

Follow up

Although he s:ll performs morphologic bone marrow tests, Dr. Pui no longer depends on them. MRD monitoring is able to provide greater sensi:vity and iden:fy disease not found on bone marrow tests, without adding significant costs.

By Jill Sederstrom

Morphology

1 - 5%

MRD

10-‐4/ 10-‐6

FLOW CYTOMETRIC DETECTION OF MINIMAL RESIDUAL DISEASE

PITFALLS

While the data on the prognosIc value of MRD are strong in pediatric ALL, the research in the adult se^ng is less extensive, and the knowledge of MRD’s role in care is more fragmented. ………………… Compared with pediatrics, the tes:ng process in adult ALL is not as structured or streamlined. With recent compara:ve analyses of ALL MRD tes:ng laboratories, the Na:onal Cancer Ins:tute (NCI) discovered that, although there was high concordance between two primary reference laboratories used by the Children’s Oncology Group (COG), the adult reference labs that parIcipated in the pilot study were not at all concordant…………“As a result, there was enthusiasm among the adult reference laboratories to par:cipate in a voluntary standardiza:on approach and adopt the COG six-‐color panel as the starIng point for that standardizaIon,” By Jill Sederstrom


PITFALLS

•  Highly specialized skills and extensive database of reference samples, which only a few laboratories have (Coustan-‐Smith E, and Campana D, 2013)

The pitfalls are depending from

• Sample quality … • Technology; the iBFM twinning program........

Possible Technical Pimalls in MRD FCM

•  Different sample in different sites of BM aspirate (different point of aspiraCon)

•  Reagents standardizaHon •  AnHgen modulaHon •  Shik immunophenotyping •  Death or apoptoCc cell evaluaCon

ALL DAY +15, “DURACLONE* TUBE

6.4 x10-3 High accuracy and reproducibility



•  Reagents standardizaHon •  AnCgen modulaCon •  Shii immunophenotyping •  Death or apoptoCc cell evaluaCon



•  Reagents standardizaCon •  AnCgen modulaCon •  Shik immunophenotyping •  Death or apoptoCc cell evaluaCon


PITFALLS

•  Highly specialized skills and extensive database of reference samples, which only a few laboratories have (Coustan-‐Smith E, and Campana D, 2013)

While the data on the prognosIc value of MRD are strong in pediatric ALL, the research in the adult se^ng is less extensive, and the knowledge of MRD’s role in care is more fragmented. ………………… Compared with pediatrics, the tes:ng process in adult ALL is not as structured or streamlined. With recent compara:ve analyses of ALL MRD tes:ng laboratories, the Na:onal Cancer Ins:tute (NCI) discovered that, although there was high concordance between two primary reference laboratories used by the Children’s Oncology Group (COG), the adult reference labs that parIcipated in the pilot study were not at all concordant…………“As a result, there was enthusiasm among the adult reference laboratories to par:cipate in a voluntary standardiza:on approach and adopt the COG six-‐color panel as the starIng point for that standardizaIon,” By Jill Sederstrom

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