biologia molecolare: leucemie mieloidi acute
TRANSCRIPT
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Biologia Molecolare: Leucemie Mieloidi Acute
Maria Teresa VosoDipartimento di Biomedicina e Prevenzione
Università Tor Vergata, Roma 20’
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Name of Company
Research support
Employee Consultant Stockholder Speaker’s Bureau
Advisory Board
Other
Celgene/BMS x x x
Astellas x
Jazz x x x
Abbvie x
Disclosures
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WHO classification of acute myeloid leukemia and related neoplasms
Arber et al., Blood 2016
*
* Defined by MDS-cytogenetics in about 30% of cases
~60-65%
~30%
~10%
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AML-MRC
Cytogenetic abnormalities
Previous history of MDS or MDS/MPNDysplasia in >50% of cells in 2 or more BM lineages, in the absence of NPM1 or CEBPA mutations
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Genetic heterogeneity of Acute Myeloid Leukemia
Dohner et al., Blood 2017
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Adapted from Dohner H et al., Blood 2017
European LeukemiaNet (ELN) 2017: prognostic stratification
with FLT3-ITDlow
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Impact of cytogenetics on survival
Analysis of 5,876 cases entered in MRC AML10, 12, and 15 trials
Grimwade D. et al., Blood. 2010*Excluding patients with t(15;17), t(8;21), inv(16), t(9;11), t(6;9), inv(3)/t(3;3). **Excluding patients with any other abnormalities listed previously.
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• Targeted resequencing of 111 myeloid cancer genes (combined with cytogenetic profiles) in 1540 AML patients
• 5,236 driver mutations (i.e. fusion genes, copy number alterations, gene mutations) involving 77 loci
• 6 genes mutated in >10% patients; 13 genes 5-10% patients; 24 genes 2-5% patients; 37 genes <2% patients
Additional mutations by NGS
Adapted from Papaemmanuil E. et al., N Engl J Med. 2016
Genomic classification
Risk-adapted strategies
Therapeutic targets
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NPM1/FLT3-ITD mutations
50-60% of NK-AML cases
One of the most frequently mutated gene in AML
Associated with good prognosis without concomitant mutation of FLT3-ITD or with FLT3-ITDlow
NPM1 represents an important prognostic indicator in AML
Pratcorona et al, Blood 2013
Overall Survival CIR
161 NPM1-mut pts, FLTD-ITDallelic ratio: high: >0.5
low: <0.5
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Other mutations
Schnittger S. et al., Blood 2011
Mutations of RUNX1 present in 10–16% of AML RUNX1mut AML is a new provisional entity in the
revised WHO classification RUNX1 mutations are associated with adverse
overall survival and with disease progression
TP53 mutations present in 5–10% of AML Prognosically unfavourable, especially in
multi-hit state
Prochazka KT. et al., Haematologica 2019
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“very favorable”
“favorable”
“intermediate”
“adverse”
“very adverse”
Patients with inv(16)/t(16;16) or biallelic
CEBPA mutations
Patients with TP53 mutations and a complex karyotype
Refinement of the 2017 ELN genetic risk stratification of AML
“favorable”
“intermediate”
“adverse”
ELN-2017
Adapted from Herold T. et al., Leukemia 2020
Refined ELN-2017Relapse-free survival
Overall survival
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- PML-RARA: 24 hours - RUNX1-RUNX1T1, CBFB-MYH11, KMT2A, (Chr 5/7 FISH panel): 2–3 days- G-banding: 1 week
- FLT3 ITD, TKD, NPM1: 72 hrs - CEBPA: 1 week
What do we need from the labs
Immunophenotype (LAIP)
1. Arber DA, Erber HP. Am J Clin Pathol 2020;154:731–41;2. Döhner H, et al. Blood 2017;129:424–47
Prior to starting treatment
To plan post-remission therapy
CEBPA, RUNX1, ASXL1, TP53or extended gene panel
or whole genome sequence
AML-MRC
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Impact of MRD in patients with AML in remission post-IC3
Identification of ≥ 0.1% MRD by multiparameter flow cytometry, or molecular methods is an important
prognostic marker that can help guide treatment (Tx) decisions
Short et al. JAMA Oncol 2020
Overall Survival Disease-free Survival
Dynamic Survival Prediction: Minimal/measurable Residual Disease (MRD)
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Preleukemic Leukemic
FLT3-ITDFLT3-TKDRASPTPN11KIT
DNMT3ATET2ASXL1IDH1/2SF3B1
PML/RARANPM1RUNX1-RUNX1T1CBFB-MYH11Other transloc.
SensitivePotentially unspecific
SpecificLost in 10-50%
SensitiveSpecific
Post-Onset Drivers
Suitability of MRD Detection Markers
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QRT-PCR for PML/RARA
Cicconi et al., Leukemia 2016, Diverio et al, Blood 2008
>60% of patients tested +ve for PML/ RARA after induction therapy
Reduction of PML/RARA after induction was greater in patients receiving ATRA–CHT
PML/RARA levels at the time point of post-induction were not predictive of subsequent relapse
Kinetics of PML/RARA clearance in pts treated with ATRA-chemo vs ATRA-ATO
Diagnosis
Post-induction
Post III consolidation
PML/RARA +ve patients by QRT-PCR Cumulative Incidence of Relapse
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MRD by RQ-PCR in PB after 2 Cycles of CHT
Ivey A et al., NEJM 2016
NPM1-mut in 2° post cons: higher risk of relapse at 3 years and lower rate of survival
BM MRD testing for NPM1-mutated AML does appear to be more sensitive than testing via PB
The presence of MRD in PB was highly informative among patients in morphologic CR
QRT-PCR for NPM1mut: PB better than BM
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Log-reduction of transcripts predicts relapse in CBF-AML
• Upfront genetics and MRD determination in CBF-AML
• 198 patients
• QRT-PCR transcripts determination after first consolidation
• A less than 3-log MRD reduction or a level >0.1% was associated with a higher specific hazard of relapse
Jourdan et al., Blood 2013
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Targeted NGS at diagnosis and after induction therapy (during CR)
Jongen-Lavrencic et al. NEJM 2018
Persistent mutations were detected in 51.4% of the patients
“DTA” mutations were most common
MRD monitoring by NGS
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Kronke et al J Clin Oncol 2011Jongen-Lavrencic M, et al. N Engl J Med
MRD: NGS vs MFC or both?
MRD, assessed by cytofluorimetry (MFC) or molecular methods, including NGS, significantly predicts relapse
NGS has significant additive value to MFC
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Normal-K AML at relapse
Greif et al, Clin Cancer Res 2018
Karyotype evolution:6/28 (21%)
Disease evolution at Relapse
Schmalbrok et al, Blood 2021
FLT3-ITD mutations
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Markers Diagnosis Prognosis MRD Targeted Th.
PML-RARA x x x x
RUNX1/RUNXT1 x x x
CBF/MYH11 x x x
NPM1mut x x x
FLT3-ITD x x
FLT3-TKD x
CEBPAmut BA x
RUNX1 x x
BCR-ABL x x x x
TP53 x
ASXL1 x
t(9;11), inv(3), t(6;9), t(1;22)
x x
MDS-RC K x x
Clinical Role of Molecular Markers
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WGS for AML diagnosis
Duncavage et al., NEJM 2021
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Personalized Medicine in AML
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Acknowledgements
M. Domenica DivonaEmiliano Fabiani
Giulia FalconiTiziana Ottone
Serena Travaglini
Giorgio ArceseFrancesco Buccisano
Maria Ilaria Del PrincipeLuca Maurillo
Raffaele PalmieriAdriano Venditti