Minimal residual disease (MRD) status is one of the most powerful predictors of disease-free and overall survival for children with ALL and testing for MRD has become a standard part of disease management and response assessment. Studies have shown that the probability of long-term relapse-free survival is directly related to the level of MRD, both early in the course of treatment and at later time points.1-19 The prognostic value of MRD measurement has also been shown in the pre- and post- allogeneic hematopoietic cell transplantation (HCT) settings.20-26 Studies investigating whether MRD status can be used to stratify children with ALL into risk groups appropriate for escalation or de-escalation of therapy are ongoing.12, 27-33
Although not as well studied as in children, MRD has been shown to be prognostic in adults with ALL at various time points during and after treatment initiation.2, 34-43 Studies have also shown that detection of MRD after allogeneic HCT is associated with an increased risk of relapse.37, 44, 45
The generally accepted threshold for MRD measurement in ALL is 10-4, primarily due to the technical limitations of the most often used measurement techniques, flow cytometry and allele-specific oligonucleotide PCR (ASO-PCR).46 The clonoSEQ® MRD Test has been shown to be concordant with both of these techniques in ALL, with most discordances attributable to the ability of the next-generation sequencing based technique to detect MRD down to the level of 10-6.5, 47
It has been shown that patients with MRD below 10-4 but ≥10-5 have a higher risk of relapse than those with a lower level of MRD or no detectable disease. These findings suggest that a stricter threshold may be more prognostic in ALL and more appropriate for risk stratified therapy approaches.19
Clinical Validation Data
The clonoSEQ MRD Test is Highly Concordant with Traditional MRD Detection Methods in ALL
- In a study of more than 100 pediatric ALL patients, sequencing-based MRD detection using the Adaptive Biotechnologies technology showed quantitative concordance with both flow cytometry ASO-PCR (Figure 1).5
- Higher sensitivity of the sequencing-based method was demonstrated by its detection of MRD in 10 and 3 patients with disease present below the detection limits of flow cytometry and ASO-PCR, respectively (Figure 1, red boxes).5
Comparison between sequencing and flow cytometry and ASO-PCR
The numbers of concordant measurements are shown in the lower left and upper right. The number of discordant measurements is shown in the upper left and lower right. Boxed numbers highlight increased sensitivity provided by sequencing- based MRD detection over other methods.
The clonoSEQ MRD Test has Demonstrated Prognostic Value in the Post-Transplant ALL Setting
- A study of peripheral blood samples from 29 adult patients with ALL who had undergone allogeneic hematopoietic stem cell transplantation found that MRD greater than one cell per million leukocytes (10-6) in the frst 100 days post-transplant, as measured with the Adaptive Biotechnologies sequencing-based method, was highly predictive of relapse (Figure 2).45
- Sequencing-based MRD detection in peripheral blood was shown to provide 3 month lead-time before clinical relapse, which could offer an opportunity to apply additional therapeutic maneuvers while disease burden is low (Figure 3).45
MRD positivity (≥10-6) at any time through day +90 post-transplant predicted subsequent relapse (HR=14; 95% CI 4.7-44; p<0.0001)
The median lead-time between sequencing-based MRD detection and clinical relapse was 89 days (range 0-207 days)
Tracking of Multiple Clones by the clonoSEQ Process Can Reduce Risk of False Negatives
- The universal primers utilized in the clonoSEQ Process allow identification and tracking of multiple malignant clones in ALL.
- In cases where multiple clones are present, not all are necessarily responsive to treatment. Other MRD methods (e.g., ASO-PCR) that follow only one clone may give false negative results, as shown in a recent clinical example (Figure 4).48
Sequencing enabled identification of 3 IGH clonal sequences at diagnosis in this ALL patient, whereas the ASO-PCR method tracked only the one sensitive to induction (Clone 1)
Relapse occurred 1 month post-induction due to clonal expansion of treatment-resistant clones not monitored by ASO-PCR
Similar results were seen in bone marrow samples
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