Detection, prevention and treatment of acute myeloid leukemia (AML) relapse.

急性髓系白血病（AML）复发的检测、预防和治疗。

• 批准号: 10008817
• 负责人: Christopher Hourigan
• 金额: $ 186.54万
• 依托单位: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10008817
• 关键词: Acute Myelocytic Leukemia; Acute leukemia; Adopted; Adult; Age; Allogenic; Area; Autologous; Bioinformatics; Biological Assay; Biological Markers; Blood; Blood specimen; Bone Marrow; Bone Marrow Aspiration; Bone Marrow Examination; Cancer Center; Cells; Characteristics; Clinic; Clinical; Clinical Trials; Collaborations; Collection; Color; Comorbidity; Congresses; Custom; Cytometry; DNA; DNA sequencing; Data Set; Detection; Development; Diagnosis; Disease remission; Drug resistance; Dysmyelopoietic Syndromes; Elderly; Eligibility Determination; Enrollment; European; Expression Profiling; FLT3 gene; Flow Cytometry; Foundations; Frequencies; Genes; Genetic Variation; Genomics; Glioblastoma; Gold; Hematology; Hematopoietic Stem Cell Transplantation; Homologous Transplantation; Human; Immune system; Immunophenotyping; Immunotherapy; In complete remission; Inferior; Intervention; JAK2 gene; Laboratories; Leukemic Cell; Logistics; Longterm Follow-up; Malignant Neoplasms; Marrow; Measurable; Measures; Medical; Methods; Modification; Molecular; Molecular Target; Morphology; Mutate; Mutation; Myeloproliferative disease; NPM1 gene; National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; Neurology; Operative Surgical Procedures; Outcome; Pathway interactions; Patient-Focused Outcomes; Patients; Performance; Phase; Polymerase Chain Reaction; Population; Prevention; Publications; Publishing; RNA Splicing; RUNX1 gene; Randomized; Randomized Clinical Trials; Recurrence; Recurrent disease; Refractory; Refractory Disease; Regimen; Relapse; Reporting; Reproducibility; Research; Residual Tumors; Residual state; Risk; Sampling; Somatic Mutation; Standardization; Survival Rate; TP53 gene; Techniques; Testing; Therapeutic; Time; Training; Transplantation; Treatment-related toxicity; United States National Institutes of Health; Validation; Variant; Work; alemtuzumab; base; burden of illness; chemotherapy; clinical risk; cohort; common treatment; conditioning; conventional therapy; drug sensitivity; exceptional responders; graft vs host disease; graft vs leukemia effect; high dimensionality; high risk; improved; individual variation; interest; leukemia; myeloblast; next generation; novel; novel marker; peripheral blood; post-transplant; preconditioning; prevent; prognostic of survival; recruit; relapse risk; response; single cell analysis; single-cell RNA sequencing; small molecule inhibitor; standard of care; stemness; success; targeted treatment; telomere; tool; transcriptome sequencing; transcriptomics; trial comparing; volunteer

The fundamental interest of the Laboratory of Myeloid Malignancies is the detection, prevention and treatment of acute myeloid leukemia (AML) relapse. Our work has focused on clinical trials of novel biomarker and immunotherapy approaches, and the development of molecular and genomic laboratory methods (Measurable Residual Disease, MRD) to predict development or recurrence of myeloid malignancy. Foundational to our objective has been the development of high sensitivity biomarkers for residual AML in those patients who have been treated to apparent remission but remain at risk of clinical relapse. Previously we have demonstrated the ability to risk stratify AML patients into groups with either high and low leukemic relapse rates, based on pre-transplant a peripheral blood sample, prior to either allogeneic (PMID: 25665046, 27185839) or autologous hematopoietic stem cell transplantation (PMID: 27544285). This year we extended our prior work in this area by investigating the impact of conditioning intensity of allogeneic transplantation (alloHCT) for acute myeloid leukemia for patients in clinical complete remission but with genomic evidence of residual disease. It is currently unknown if modulating the intensity of the alloHCT conditioning regimen in AML patients testing positive for MRD can prevent relapse and improve survival rates. BMT CTN 0901 NCT NCT01339910 was a phase III randomized clinical trial comparing outcomes by conditioning intensity in adult patients with myeloid malignancy undergoing an alloHCT in morphological complete remission (ie: <5% marrow myeloblasts at the time of pre-transplant assessment, CR). We aimed to determine the impact of alloHCT conditioning intensity on post-transplant outcomes in AML patients in CR but with pre-transplant genomic evidence of residual disease. We used ultra-deep error-corrected DNA sequencing, using a custom 51kb anchored multiplex PCR panel with coverage of 13 commonly mutated genes in AML (ASXL1, DNMT3A, FLT3, IDH1, IDH2, JAK2, KIT, NPM1, NRAS, RUNX1, SF3B1, TET2 and TP53) on pre-conditioning blood samples of 190 AML patients from the BMT CTN 0901 study receiving either myeloablative (MAC) or reduced intensity conditioning (RIC). These subjects were well matched for other baseline characteristics. We showed that detection of an AML-associated variant using ultra-deep next-generation DNA sequencing in the blood of AML patients in CR prior to alloHCT was associated with increased relapse rate and inferior overall survival in those randomized to RIC. This study provides strong evidence that intervention for AML patients with MRD can result in improved survival. This work was presented, as a late-breaking abstract, at the Presidential Plenary Session of the European Hematology Association Annual Congress in Amsterdam (LBA2600, June 14th 2019) and is currently being prepared for publication. In addition, this year with Dr Gottesman of NCI we published a report of our collaboration investigating drug resistance in AML. Through transcriptomic analysis of 154 cases of treatment-naive AML, three chemorefractory patient groups with distinct expression profiles were identified. A classifier, trained based on the expression profile of the highest risk refractory patients, was validated in an independent cohort (n = 131), was prognostic for overall survival (OS) and refined an established 17-gene stemness score. Ex vivo drug sensitivity to 122 small-molecule inhibitors revealed effective potential group-specific targeting of pathways among these three refractory groups (Ref 2). We also reported long-term follow-up analysis of patients with Myelodysplastic Syndrome (MDS) treated on a phase 1/2 pilot clinical trial of alemtuzumab (05-H-0206, NCT00217594) which enrolled 39 patients at the NIH Clinical Center between 2005 and 2013. This report highlighted six exceptional responders who remained alive and in complete hematologic remission 5 years from enrollment (Ref 2). DNA-based sequencing is not capable of tracking the approved European LeukemiaNet molecular targets for AML MRD. We therefore developed, using iterative modifications and novel bioinformatics approaches, a novel RNA-sequencing assay with greater than 100-fold increase in performance compared with some commercially available targeted RNA-sequencing approaches and a limit of detection as low as one leukemic cell in 100,000 cells measured, which is comparable to gold-standard quantitative polymerase chain reaction analysis. This assay, which can be customized and expanded, is the first demonstrated use of high-sensitivity RNA-sequencing for measurable residual disease detection in acute myeloid leukemia and could serve as a broadly applicable standardized tool (Ref 3). Our systematic and comprehensive assessment of human bone marrow using genomic and immunophenotyping high dimensional single-cell analysis was also published during this period (Ref 4). We recruited a cohort of twenty healthy adult volunteers for collection of research samples from bone marrow aspiration for analysis by droplet-based single cell RNA sequencing, 13-color flow cytometry and mass cytometry. This unique dataset serves for a healthy control cohort across the full range of adulthood (age 24-84) providing not only cell population frequencies and characteristics, but also highlighting individual variation in human cohorts and reproducibility and correlation between these techniques. In conjunction with Drs McReynolds, Holland and Calvo we completed genomic analysis for recurrent AML somatic mutations in bone marrow samples from patients with germline GATA2 mutation and either progression to AML (Ref 5), or with MDS or a pre-MDS state (Ref 6). For AML MRD in the clinic, our analysis of our clinical trial for AML patients with relapsed or refractory disease, PEARL15: Personalized Early Assessment of Response During Salvage Chemotherapy in People with Relapsed or Refractory Acute Myeloid Leukemia (PEARL15, 15-H-0176, NCT02527447) was published. This trial sought to test the hypothesis that high-sensitivity assays for residual disease burden may allow much earlier assessment (day 4 in blood, compared with day 28-42 from cytomorphological examination of bone marrow conventionally) of the success of therapy for relapsed and refractory AML (Ref 7). Finally, in addition to those described above a number of impactful collaborations were completed and published this year; with the BeatAML group (Ref 9), with Dr. Neal Young in the Hematology Branch of NHLBI on high-sensitivity detection of telomere variants (Ref 10), with the group of Dr. Dan Larson of NCI on the U2AF1 splicing factor in AML (Ref 11), with Dr Edjah Ndoum of the Surgical Neurology Branch of NINDS (MDS/AML associated somatic mutations in patients with Glioblastoma, Ref 12) and with Drs. Daver, Sharma, Kantarjian and Allison of MD Anderson Cancer Center (Ref 13). In summary, the primary interest of the Myeloid Malignancies Section remains the detection, prevention and treatment of AML relapse, in particular the development of molecular and genomic laboratory methods to predict development or recurrence of myeloid malignancy. In the past year we have completed a large study involving ultra-deep error-corrected DNA sequencing of AML patients treated on a phase III randomized clinical trial and showed for the first time that intervention can change meaningful clinical outcomes for patients with AML MRD. Going forward we will continue to integrate genomic and immunophenotypic approaches on carefully annotated clinical samples to better understand myeloid malignancy.

髓样恶性肿瘤实验室的基本兴趣是急性髓样白血病（AML）复发的检测，预防和治疗。我们的工作集中在新型生物标志物和免疫疗法方法的临床试验上，以及分子和基因组实验室方法的发展（可测量的残留疾病，MRD），以预测髓样恶性肿瘤的发展或复发。 我们目标的基础是那些接受过明显缓解但仍有临床复发风险的患者的残留AML的高灵敏度生物标志物的发展。以前，我们已经证明了将AML患者分为较高和低白血病复发率的类别的能力，基于移植前的外周血样本（PMID：25665046，27185839）或自体造血干细胞移植（PMID：PMID：PMID：PMID：PMID：275544285）。今年，我们通过研究了同种异体移植（AllOHCT）对急性髓细胞性白血病的临床完全缓解患者的调节强度（ALLOHCT）的影响，从而扩展了这一领域的先前工作，但具有残留疾病的基因组证据。 目前尚不清楚AML患者在MRD阳性的AML患者中调节AllOHCT调节方案的强度是否可以防止复发并提高存活率。 BMT CTN 0901 NCT NCT NCT01339910是一项III期随机临床试验，通过调节髓样恶性肿瘤的成年患者的调节强度，在形态完全缓解中进行全hip（即：<5％骨髓骨髓骨髓骨髓肌细胞的强度），在转移前评估时，CR，CR）。 我们的目的是确定ALLOHCT调节强度对CR中AML患者移植后结局的影响，但具有移植前的基因组证据的残留疾病。 We used ultra-deep error-corrected DNA sequencing, using a custom 51kb anchored multiplex PCR panel with coverage of 13 commonly mutated genes in AML (ASXL1, DNMT3A, FLT3, IDH1, IDH2, JAK2, KIT, NPM1, NRAS, RUNX1, SF3B1, TET2 and TP53) on pre-conditioning blood samples of 190来自BMT CTN 0901研究的AML患者接受骨髓性（MAC）或降低强度调节（RIC）。这些受试者在其他基线特征方面非常匹配。我们表明，使用超深下一代DNA测序在AML患者的血液中检测AML相关的变体在ALLOHCT之前的血液中检测与复发率的提高和随机分配至RIC的复发率和较低的总体存活有关。这项研究提供了有力的证据，表明对AML MRD患者的干预可以改善生存率。这项工作是在阿姆斯特丹举行的欧洲血液学协会年度大会（LBA2600，2019年6月14日）的欧洲血液学协会年度大会上，作为一本突破性的摘要介绍了这项工作，目前正在准备发表。 此外，今年，与NCI的Gottesman博士一起，我们发表了一份关于AML中耐药性的合作调查的报告。 通过对154例治疗AML病例的转录组分析，确定了三个具有不同表达谱的化学浪费患者组。基于最高风险难治性患者的表达谱的分类器在独立队列中得到了验证（n = 131），对整体生存率（OS）进行了预后，并完善了已建立的17基因茎评分。对122个小分子抑制剂的体内药物敏感性显示，这三个难治性组之间有效的群体特异性靶向（参考文献2）。 We also reported long-term follow-up analysis of patients with Myelodysplastic Syndrome (MDS) treated on a phase 1/2 pilot clinical trial of alemtuzumab (05-H-0206, NCT00217594) which enrolled 39 patients at the NIH Clinical Center between 2005 and 2013. This report highlighted six exceptional responders who remained alive and in complete hematologic remission 5 years from enrollment (Ref 2）。 基于DNA的测序无法跟踪AML MRD的批准的欧洲白血病分子靶标。 因此，我们使用迭代修饰和新型的生物信息学方法开发了一种新型的RNA序列测定法，与某些市售靶向的RNA序列方法相比，性能提高了100倍以上，并且在100,000个细胞中的一个白细胞细胞限制的限制，可与金标准量相比，与金标准量相比，这与金标准量相比。该测定方法可以自定义和扩展，是首次证明使用高敏感性RNA测序，用于急性髓样白血病中可测量的残留疾病检测，并且可以用作广泛适用的标准化工具（参考文献3）。 在此期间，还发表了使用基因组和免疫表型高维单细胞分析对人体骨髓进行系统和全面评估（参考文献4）。我们招募了一组二十名健康的成年志愿者，从骨髓抽吸中收集了研究样本，以基于液滴的单细胞RNA测序，13色流式细胞仪和质量细胞仪分析。 这个独特的数据集可用于整个成年范围（24-84岁）的健康控制队列，不仅提供了细胞种群的频率和特征，而且还强调了这些技术之间人类队列中的个体变化以及可重复性和相关性。 与McReynolds博士，荷兰和CALVO博士一起，我们完成了基因组分析，用于来自生殖线GATA2突变患者的骨髓样品中的复发AML体细胞突变，并且进展为AML（参考文献5），或者使用MDS或MDS或Pre-MDS状态（参考文献6）。 对于诊所中的AML MRD，我们对AML复发或难治性疾病患者的临床试验分析，PEARL15：对复发或难治性急性髓样白血病患者的挽救化疗期间反应的个性化早期评估（Pearl15，15-H-0176，NCT0252276，NCT02527447）。该试验试图检验以下假设：残留疾病负担的高敏化测定可能会允许更早的评估（与经常对骨髓的细胞学形态学检查相比，第4天血液中的第4天）是对复发和顽固性AML的成功疗法的成功（参考7）。 最后，除了上面描述的那些有影响力的合作外，今年还完成了许多有影响力的合作； with the BeatAML group (Ref 9), with Dr. Neal Young in the Hematology Branch of NHLBI on high-sensitivity detection of telomere variants (Ref 10), with the group of Dr. Dan Larson of NCI on the U2AF1 splicing factor in AML (Ref 11), with Dr Edjah Ndoum of the Surgical Neurology Branch of NINDS (MDS/AML associated somatic mutations in patients with胶质母细胞瘤，参考12）和Drs。 MD安德森癌症中心的Daver，Sharma，Kantarjian和Allison（参考文献13）。 总而言之，髓样恶性肿瘤部分的主要利益仍然是AML复发的检测，预防和治疗，尤其是分子和基因组实验室方法的发展，以预测髓样恶性肿瘤的发展或复发。在过去的一年中，我们已经完成了一项大型研究，涉及在III期随机临床试验中治疗的AML患者进行超深误差的DNA测序，并首次表明干预措施可以改变AML MRD患者的有意义的临床结果。展望未来，我们将继续在精心注释的临床样本上整合基因组和免疫表型方法，以更好地了解髓样恶性肿瘤。