does monitoring of chimerism predict relapse and allow · pdf filedoes monitoring of chimerism...
TRANSCRIPT
![Page 1: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/1.jpg)
Does monitoring of chimerism
predict relapse and allow
pre-emptive immunotherapy?
David Grimwade
Dept. of Medical & Molecular Genetics,
King’s College London School of Medicine, UK
NO!
![Page 2: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/2.jpg)
Investigation of chimerism to predict relapse
post-transplant & guide immunotherapy in AML
Huisman et al. Bone Marrow Transplant 2007; 39: 285-91. Rettinger et al. Blood 2011; 118: 5681-8
CC – Complete Chimerism; MC – Mixed Chimerism;
d-MC – decreasing MC; i-MC – increasing MC
Pro
ba
bilit
y o
f re
ma
inin
g r
ela
pse
fre
e
p<0.000
![Page 3: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/3.jpg)
Schmid et al. J Clin Oncol 2007; 25: 4938-35.
Disease relapse remains a major cause of failure
following allogeneic transplant, with poorer
response to DLI with higher tumour burden
![Page 4: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/4.jpg)
Are chimerism assays fit for purpose to predict relapse?
Issues of standardisation & sensitivity
![Page 5: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/5.jpg)
Exploring the use of over-expressed genes
to track treatment response in AML
Compared to level of expression in
normal PB & BM:
WT1 is sufficiently over-expressed
to discriminate 2-log reduction in
transcripts in 46% and 13% of AML,
according to follow-up sample source
Cilloni et al, J Clin Oncol 2009, 27: 5195-201
204 control samples
620 AML samples
Wilms Tumour gene (WT1) Control samples: n=204
AML samples: n=620
![Page 6: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/6.jpg)
Development of standardised RT-qPCR
assays for detection of WT1 transcripts
3 assays eliminated:
•Cross-reactivity with
genomic DNA (n=1)
•Low sensitivity (n=2)
3 assays eliminated:
•Reduced efficiency & sensitivity (n=3)
Best-performing WT1
assay selected:
•Designated ELN WT1 assay
Phase IPhase I
9 WT1 assays evaluated:
•Cell line dilutions
•Genomic DNA
Phase 2Phase 2
6 WT1 assays evaluated:
•Plasmid standards
Phase 3Phase 3
3 WT1 assays evaluated:
•Cell line dilutions
•Plasmid standards
Phase 4Phase 4
Evaluation of ELN assay
•Normal PB/BM/PBSCs (n=204)
•Diagnostic AML samples (n=620)
•Follow-up samples from 145 pts
Cilloni et al, J Clin Oncol 2009, 27: 5195-201
![Page 7: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/7.jpg)
Pozzi et al, Br J Haematol 2013: 160: 503-9
Investigation of optimised ELN WT1 assay to predict
outcome & guide therapy post-allogeneic transplant in AML
Association between WT1 level post-transplant & relapse Survival following DLI in patients with higher WT1 levels
BM samples analysed with ELN WT1 assay
>180 copies WT1 / 104 ABL used as definition of MRD positivity
![Page 8: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/8.jpg)
Are chimerism assays sophisticated
enough to reliably predict disease relapse?
![Page 9: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/9.jpg)
Development of standardised leukaemia-specific
RT-qPCR assays to track treatment response & guide therapy
1000
100
10
1
0.1
0.01
0.001
Fu
sio
n g
en
e /
AB
L
No
rmalised
co
py n
um
ber
22 31 23 20 57 29 17 24 22 27 n =
AML1-ETO
CBFB-MYH11
PML-RARA
SIL-TAL1
TEL-AML1
p210 CML
p210 ALL
p190 ALL
MLL-AF4
E2A-PBX1
Gabert et al, Leukemia 2003; 17: 2318
Europe Against Cancer
![Page 10: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/10.jpg)
Sequential monitoring for leukaemia-
specific transcripts to predict relapse
NPM1 mutant AML
•246 patients
•1441 samples
Adam Ivey, Neesa Bhudia,
Mandy Gilkes, Rosemary Gale
NCRI AML17 trial
![Page 11: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/11.jpg)
Use of MRD monitoring to direct pre-
emptive azacitidine therapy post-SCT
Sockel et al. Haematologica 2011; 96: 1568-70.
![Page 12: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/12.jpg)
Standardised JAK2-V617F qPCR assay improves
prediction of relapse following allogeneic SCT
•JAK2-V617F detected:
•Median of 22 weeks (range 6–85 weeks) before relapse
•Median of 86 days (45-595 days) before loss of full donor chimaerism
•Early intervention with DLI associated with better outcome (Kröger et al, Blood 2009)
Jovanovic et al. Leukemia 2013.
![Page 13: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/13.jpg)
Ley TJ & colleagues: New Engl J Med 1st May, 2013
• NGS of 200 AML cases
• (50 whole genome, 150 exome)
• Average of 13 gene mutations/AML
• 23 genes significantly mutated
• >200 genes mutated in ≥2 cases
• >1000 genes mutated overall
![Page 14: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/14.jpg)
Potential of next generation sequencing
approaches to track treatment response
Thol et al. Genes Chromosomes Cancer 2012.
Diagnosis
Remission
Relapse
Detection of DNMT3A mutation by next generation sequencing
FLT3-ITD
NPM1 mut
DNMT3A mut
Ivey A, Simpson MA, Burnett AK & Grimwade D, unpubl.
![Page 15: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/15.jpg)
•Relapses can occur despite full donor chimerism
•Durable remissions in patients with mixed chimerism
How reliable are chimerism assays
to predict relapse?
![Page 16: Does monitoring of chimerism predict relapse and allow · PDF fileDoes monitoring of chimerism predict relapse and allow pre-emptive immunotherapy? ... transcripts in 46% and 13% of](https://reader031.vdocument.in/reader031/viewer/2022030510/5abab0747f8b9ab1118c2375/html5/thumbnails/16.jpg)
Time to upgrade?
0.0001
0.001
0.01
0.1
1
10
100
1000
10000
100000
0 1 2 3 4 5 6 7 8 9
NP
M1
mu
tA c
n/1
0^
-4 A
BL
Months post diagnosis