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: 10253876
• 负责人: Christopher Hourigan
• 金额: $ 163.75万
• 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/10253876
• 关键词: Acute Myelocytic Leukemia; Adult; Age; Allogenic; American Society of Hematology; Area; Aspirate substance; Autologous; Biological Assay; Biological Markers; Blood; Blood specimen; Bone Marrow; Bone Marrow Examination; Cessation of life; Characteristics; Clinic; Clinical; Clinical Trials; Collaborations; Congresses; Custom; Cytokine Network Pathway; DNA sequencing; Detection; Development; Diagnosis; Disease remission; Dysmyelopoietic Syndromes; Elderly; European; FLT3 gene; Foundations; Genes; Genetic Variation; Genomics; Guidelines; Hematology; Hematopoietic Neoplasms; Human; IL8 gene; Immunotherapy; Individual; Inferior; Intervention; JAK2 gene; Laboratories; Malignant Neoplasms; Marrow; Measurable; Medical; Methods; Molecular; Morphology; Mutate; Mutation; Myeloproliferative disease; NPM1 gene; National Heart, Lung, and Blood Institute; Newly Diagnosed; Oral; Outcome; Patient-Focused Outcomes; Patients; Phase; Prevention; Proteomics; Published Comment; Publishing; RUNX1 gene; Randomized; Randomized Clinical Trials; Recurrence; Recurrent disease; Refractory; Refractory Disease; Regimen; Relapse; Residual Tumors; Residual state; Risk; Sampling; Sampling Studies; Sickle Cell Anemia; Signal Transduction; Survival Rate; TP53 gene; Testing; Time; Transplantation; Transplantation Conditioning; United States National Institutes of Health; Universities; Variant; Work; arm; base; burden of illness; chemokine; chemotherapy; clinical center; clinical risk; comorbidity; conditioning; disorder risk; experience; hematopoietic cell transplantation; high risk; improved; interest; leukemia; myeloblast; next generation; novel; novel marker; peripheral blood; post-transplant; preconditioning; prevent; prognostic; proteomic signature; relapse risk; response; sex; success; targeted treatment; transcriptome sequencing; trial comparing

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 a pre-transplant peripheral blood sample, prior to either allogeneic (PMID: 25665046, 27185839) or autologous hematopoietic cell transplantation (PMID: 27544285). This year we extended our prior work in this area by investigating the impact of conditioning intensity of allogeneic hematopoietic cell transplantation (alloHCT) for AML patients in clinical complete remission but with genomic evidence of residual disease. It was 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 (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 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 (Ref 1). We then extended this work further to study samples from patients with myelodysplastic syndrome (MDS) who were treated on the same BMT CTN 0901 trial. Using the previously described set of 10 gene regions (as above, minus DNMT3A, TET2 and ASXL1), 42% of patients had mutations detectable prior to randomization to reduced intensity or myeloablative conditioning. Testing positive was associated with increased rates of relapse and decreased overall survival. In those testing positive, relapse rates were higher and relapse-free survival was lower in reduced intensity versus myeloablative conditioning arms. Testing additional genes, including those associated with MDS, did not improve prognostication. This study provided evidence that post-transplant relapse rates in MDS patients are highest in those with pre-transplant genomic evidence of high-risk disease. In those testing positive, randomization to myeloablative conditioning lowered but did not eliminate relapse risk. This work was selected for oral presentation at the 25th European Hematology Association Congress (June 2020). We extended our interest in measurable genomic evidence of myeloid malignancy further by performing, in collaboration with Dr. Fitzhugh of NHLBI, detailed genomic leukemic characterization of 2 of the 3 patients who developed myeloid malignancy post-transplantation out of a total of 76 adult patients who received an AlloHCT for Sickle Cell Disease at the National Institutes of Health Clinical Center between September 2004 and April 2018. We showed that TP53 mutations present at the time of malignancy diagnosis were also detectable before transplantation (Ref 2). Using primary samples from our AML patients, together with sex and age matched healthy donors, we performed paired RNA-sequencing and highly multiplexed proteomic assessment of human bone marrow aspirates. This showed that a highly connected signaling network of cytokines and chemokines, including IL-8, was most prominent proteomic signature associated with AML in the BM microenvironment (Ref 3). For AML MRD in the clinic, our experience using the approach of "timed sequential salvage chemotherapy" on 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 year (Ref 4). 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. In addition to invited expert commentary and review of the topic of AML MRD (Refs 5, 6 and 7), we also participated in published collaborations with Dr Sung and colleagues at Duke University on novel allogeneic hematopoietic cell transplantation for AML (Ref 8), with Dr. Mehta of NHLBI (Ref 9) and as part of an expert group assembled by the American Society of Hematology for their 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults (Ref 10). 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组的能力，基于移植前的外围血液样本（PMID：PMID：25665046，27185839）或自体造血细胞移植（PMID：PMID：PMID：PMID：PMID：2755444285）。 今年，我们通过研究了同种异体造血细胞移植（AllOHCT）对AML患者的临床完全缓解中的AML患者的调节强度的影响，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。 在AML患者中测试MRD阳性的AML患者的AllOHCT调节方案的强度是否可以防止复发并提高存活率是未知的。 BMT CTN 0901（NCT01339910）是一项III期随机临床试验，通过调节骨髓恶性肿瘤的成年患者的强度，在形态完全缓解中进行全hip（IE：<5％骨髓骨髓骨髓肌细胞，在移植前评估时，都会在形态上完全缓解（<5％）。 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 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研究接受了骨髓性（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（参考文献1）。 然后，我们进一步扩展了这项工作，以研究在同一BMT CTN 0901试验中接受治疗的骨髓增生综合征（MDS）患者的样本。 使用先前描述的10个基因区域集（如上所述，减去DNMT3A，TET2和ASXL1），有42％的患者在随机分组之前可检测到突变以降低强度或骨髓性调理。测试阳性与复发率增加和总体生存率降低有关。在那些测试阳性的人中，复发率较高，无复发生存率降低，强度降低与髓质疾病臂相比。测试其他基因，包括与MDS相关的基因，并不能改善预后。这项研究提供了证据表明，在移植前基因组疾病的基因组证据中，MDS患者的移植后复发率最高。在那些测试阳性的那些过程中，随机分配给骨髓性调节的人降低但没有消除复发风险。 这项工作被选为在第25届欧洲血液学协会大会（2020年6月）进行口头介绍。 我们通过与NHLBI的Fitzhugh博士合作进行了对髓样恶性肿瘤的可测量基因组的兴趣，对3名在转移后的骨髓性恶性肿瘤发展的3例患者中有2名患者中有76名成年患者在National Internation Allohct anderical Intern in Sunderiation and National Insterial nistriit and national Internity中，对3例骨髓性恶性肿瘤进行了详细的基因组性白血病表征。在移植前还可以检测到在恶性诊断时存在的TP53突变（参考文献2）。 使用来自AML患者的主要样本，以及性别和年龄匹配的健康供体，我们对人骨髓吸质物进行了配对的RNA测序和高度多重的蛋白质组学评估。 这表明，包括IL-8在内的细胞因子和趋化因子的高度连接的信号网络是与BM微环境中AML相关的最突出的蛋白质组学特征（参考文献3）。 对于诊所中的AML MRD，我们的经验在我们对AML复发或难治性疾病的临床试验中使用“定时挽救化学疗法”的方法，Pearl15：在抢救化学疗法中的个性化早期评估，对患有复发性或顽固性急性肌动症的人（Pearl15，15-15-H-0176，NCT177），对反应的早期评估， （参考4）。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允许更早的评估（与常规上骨髓的细胞晶状体形态学检查相比，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。 除了邀请专家评论和对AML MRD主题（参考文献5、6和7）的评论外，我们还参加了与杜克大学新颖的同异源性造血细胞移植的AML移植（Ref 8）的出版与NHLBI的Mehta（Ref 9）的合作（参考文献9），并由NHLBI的Mehta博士（参考文献9）合作（参考文献8）（参考文献9）在老年人中治疗新诊断的急性髓样白血病（参考文献10）。 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。