Outcomes of Measurable Residual Disease in Pediatric Acute Myeloid Leukemia before and after Hematopoietic Stem Cell Transplant: Validation of Difference from Normal Flow Cytometry with Chimerism Studies and Wilms Tumor 1 Gene Expression

Abstract

We enrolled 150 patients in a prospective multicenter study of children with acute myeloid leukemia undergoing hematopoietic stem cell transplantation (HSCT) to compare the detection of measurable residual disease (MRD) by a "difference from normal" flow cytometry (ΔN) approach with assessment of Wilms tumor 1 (WT1) gene expression without access to the diagnostic specimen. Prospective analysis of the specimens using this approach showed that 23% of patients screened for HSCT had detectable residual disease by ΔN (.04% to 53%). Of those patients who proceeded to transplant as being in morphologic remission, 10 had detectable disease (.04% to 14%) by ΔN. The disease-free survival of this group was 10% (0 to 35%) compared with 55% (46% to 64%, P < .001) for those without disease. The ΔN assay was validated using the post-HSCT specimen by sorting abnormal or suspicious cells to confirm recipient or donor origin by chimerism studies. All 15 patients who had confirmation of tumor detection relapsed, whereas the 2 patients with suspicious phenotype cells lacking this confirmation did not. The phenotype of the relapse specimen was then used retrospectively to assess the pre-HSCT specimen, allowing identification of additional samples with low levels of MRD involvement that were previously undetected. Quantitative assessment of WT1 gene expression was not predictive of relapse or other outcomes in either pre- or post-transplant specimens. MRD detected by ΔN was highly specific, but did not identify most relapsing patients. The application of the assay was limited by poor quality among one-third of the specimens and lack of a diagnostic phenotype for comparison.

Novel Disease Risk Model for Patients with Acute Myeloid Leukemia Receiving Allogeneic Hematopoietic Cell Transplantation

“…However, outcomes vary widely in patients who undergo transplantation while in remission. Using new sensitive methods such as multiparameter flow cytometry and molecular techniques allow treating physicians to better detect MRD, which has emerged as an independent prognostic factor after transplant [16,[33][34][35][36]. Impact of depth of responses before transplant on post-transplant survival was also demonstrated in the current study.…”

Highly sensitive chimerism detection in blood is associated with increased risk of relapse after allogeneic hematopoietic cell transplantation in childhood leukemia

“…In AML, MRD is most frequently monitored by flow cytometry with two to three logs lower sensitivities than in ALL . More sensitive PCR‐based analysis can be used in only 50% of children with AML, and with the risk of loss of markers or persistence of fusion transcripts, the interpretation is complicated . Furthermore, MRD is primarily analyzed on bone marrow samples, which limits the frequency of measurements in children.…”

The Development of Personalized Medicine: Acute Myeloid Leukemia as a Model

“…51 Despite being shown to relate with patient outcome in many studies, using WT1 expression as a MRD marker is still controversial due to its low sensivity. 51,[55][56][57] More recent technologies such as Next generation sequencing (NGS) and droplet digital PCR (ddPCR) are ideal to be used in all patients. NGS gives the whole genetic profile of the patient while ddPCR allows simultaneous multiple gene expression quantification.…”