YES & YES! YES & YES! David Grimwade Dept. of Medical - PowerPoint PPT Presentation

“Can novel prognostic Can novel prognostic “ markers predict for success markers predict for success and guide therapy in AML? ?” ” and guide therapy in AML YES & YES! YES & YES! David Grimwade Dept. of Medical & Molecular Genetics, King’s College London School of Medicine

The need for novel prognostic markers: The need for novel prognostic markers: Widely accepted pre- -treatment risk factors used to determine AML treatment risk factors used to determine AML Widely accepted pre therapy cannot reliably distinguish patients who will/will not relapse elapse therapy cannot reliably distinguish patients who will/will not r Grimwade et al , Blood 1998; 92: 2322-2333

Trial groups can’ ’t even agree about t even agree about Trial groups can standard risk factors! standard risk factors! MRC MRC SWOG/ECOG SWOG/ECOG CALGB CALGB GIMEMA/AML10 GIMEMA/AML10 GERMAN GERMAN AMLCG AMLCG MRC MRC SWOG/ECOG SWOG/ECOG CALGB CALGB GIMEMA/AML10 GIMEMA/AML10 GERMAN AMLCG GERMAN AMLCG t(15;17) t(15;17) t(15;17) t(15;17) t(15;17) Favourable t(8;21) t(8;21) (lacking del(9q), t(8;21) t(8;21) t(8;21) complex i.e.  3 unrel inv(16)/t(16;16) inv(16)/t(16;16) inv(16)/t(16;16) inv(16)/t(16;16) abn) inv(16)/t(16;16)/ del(16q) Normal Normal Normal Normal Normal Intermediate Other non-complex +6, +8, -Y, del(12p) Other non- -Y Other non- complex complex abn(3q) [exclud t(3;5)] abn(3q), (9q), (11q), inv(3)/t(3;3) Other inv(3)/t(3;3) (21q), abn(17p) -7 -5/del(5q) inv(3)/t(3;3), -5/del(5q) t(6;9) -7/del(7q) add(5q)/del(5q), -5, Adverse -7/del(7q) t(6;11) abn(11q23) add(7q)/del(7q), -7 t(6;9) t(11;19) del(12p) t(6;11), t(10;11), t(9;22) +8 abn(17p) complex (  3 unrel abn) complex (  3 unrel complex (  3 unrel Other t(11q23) [exclud t(9;11) & t(11;19)] abn) abn) (excluding those t(9;22), -17/abn(17p), with favourable complex (>4 unrel abn) changes) (excluding those with favourable changes)

Limitations to using diagnostic karyotype karyotype Limitations to using diagnostic for treatment stratification for treatment stratification • Conflicting data regarding prognostic significance of some primary cytogenetic aberrations – Influences of sample size & treatment variation • Incorrect risk group assignment – Unsuccessful cytogenetic analysis – Cryptic rearrangements • Normal karyotype (~40% AML) molecularly heterogeneous

Molecular advances over last decade have substantially Molecular advances over last decade have substantially improved outcome prediction & risk stratification improved outcome prediction & risk stratification • Favourable 24%: t(15;17)/ PML-RARA , t(8;21)/ AML1-ETO , inv(16)/ CBFB-MYH11 2000 • Intermediate 61%: Normal karyotype, other cytogenetic abonormalities • Adverse 15%: -5/del(5q), -7, abn(3q), complex 2010 38% 45% 17%

Integration of cytogenetic and molecular markers Integration of cytogenetic and molecular markers to predict outcome in AML to predict outcome in AML t(15;17) t(8;21) NPM mut/ ITD neg inv(16) CEBPA biallelic Other intermediate FLT3-ITD/ NPM wt Other adverse

Importance of molecular diagnostics to guide appropriate therapy • Case History – 75yr old female – WBC 15 x 10 9 /l – Suspected M3v – Randomised to AIDA in NCRI AML17 trial – Cytogenetics: Normal – FISH: No PML-RARA fusion signal – Diagnosis: RT-PCR: PML-RARA neg Diagnosis: NPM1 mutant AML

Is it APL? Importance of molecular diagnostics to guide therapy • Case History – 25yr old female – Presented – PE (23.12.09) – FBC: Hb 10g/dl, WBC 0.5, Plt 86 – Marrow – APL? – Cytogenetics: Normal – FISH: No PML-RARA fusion signal – PML antibody test +ve PML antibody test +ve – RT-PCR: PML-RARA +ve (reciprocal RARA-PML neg) RT-PCR: PML-RARA +ve (reciprocal RARA-PML neg) – Diagnosis: APL secondary to PML-RARA insertion Diagnosis: APL secondary to PML-RARA insertion  ATRA + Idarubicin

Early detection of MRD provides Early detection of MRD provides independent prognostic information in AML independent prognostic information in AML Flow cytometry cytometry RQ- -PCR PCR (WT1) Flow RQ (WT1) San Miguel et al , Blood 1997 Cilloni et al , J Clin Oncol 2009 MRD post-induction 100 < 5x10 -3 (n=24) 75 p =0.004 for each increasing p =0.01 log reduction in WT1 50 % in CR ≥ 5x10 -3 (n=18) 25 10 20 30 40 50 60 70 Months from diagnosis Independent prognostic factor: Independent prognostic factor: San Miguel et al , Blood 2001 WT1 log reduction assessed by ELN standardised assay Kern et al , Blood 2004 remains significant when adjusting for age, presenting Maurillo et al , J Clin Oncol , 2008 WBC & cytogenetics Rubnitz et al , Lancet Oncol , 2010

Use of sequential MRD monitoring to direct Use of sequential MRD monitoring to direct pre- -emptive therapy to prevent impending relapse emptive therapy to prevent impending relapse pre Leukaemic cell burden cell burden Leukaemic >10 12 Pre- Pre -emptive therapy emptive therapy to prevent frank relapse to prevent frank relapse 10 10 Rapid Slow Rapid Slow responders responders responders responders 10 8 10 6 MRD undetectable range

Sequential MRD monitoring for PML RARA transcripts by standardised transcripts by standardised Sequential MRD monitoring for PML- -RARA Europe Against Cancer (EAC) RQ- Europe Against Cancer (EAC) RQ -PCR assay to predict relapse in APL PCR assay to predict relapse in APL Diagnosis Relapse Relapse 1 Normalised PML-RARA transcript level Molecular ( PML-RARA copies/ ABL copies) relapse 0.1 pml rara/abl sensitivity abl 0.01 0.001 0.0001 06.05.02 06.06.02 30.07.02 11.11.02 05.12.02 23.12.02 06.01.03 06.02.03 24.03.03 22.05.03 26.06.03 14.08.03 07.11.03 08.01.04 04.05.04 S-DAT/ S-DAT/ MACE/MiDAC ATO Mylotarg Na valproate FLAG-ida ATRA Theophylline Treatment since diagnosis

Serial MRD monitoring by standardised RQ- -PCR assay PCR assay Serial MRD monitoring by standardised RQ to guide patient management in PML + APL to guide patient management in RARA + APL PML- -RARA Case History: 9 month male infant FBC: Hb 8g/dl, WBC 28.6 x 10 9 /l, Plt 12 x 10 9 /l PML-RARA + APL Persistent disease Persistent disease AlloSCT ATO ATO Maint ATO Ongoing ATRA + Molecular CR Chemo

Evaluation of MRD monitoring & pre- -emptive therapy to reduce emptive therapy to reduce Evaluation of MRD monitoring & pre rates of frank relapse in PML + APL in MRC AML15 trial rates of frank relapse in RARA + APL in MRC AML15 trial PML- -RARA Cost effectiveness of MRD monitoring Cost effectiveness of MRD monitoring Assuming monitoring cost of £3,000/patient & life expectancy of 25y for patients successfully salvaged: • WBC>10: 10% survival benefit at 5 years - £1,350/ quality adjusted life year (QALY) • WBC<10: 1% survival benefit at 5 years - £14,300/QALY Grimwade et al, J Clin Oncol 2009; 27: 3650-8.

MRD detection of mutant NPM1 NPM1 by RQ by RQ- -PCR in MRC AML15 PCR in MRC AML15 MRD detection of mutant 1000 Relapse Relapse Relapse Relapse Relapse Relapse Relapse Relapse 100 Normalised copy number: NPM1 mutant/ ABL 10 Relapse Relapse 4 mo later 4 mo later 1 15-0349 NPM1 mut/ ABL CN 15-1079 15-1172 0.1 Relapse Relapse 15-1468 6 mo later 6 mo later 15-1596 15-1612 0.01 15-1631 15-2336 0.001 CR CR 0.0001 0.00001 CCR 12 mo later CCR 12 mo later 0.000001 0 2 4 6 8 10 12 14 16 18 Months PCR positive Months from diagnosis PCR negative Semin Oncol 2008;35:388-400.

In favour of the motion: In favour of the motion: • Molecular diagnostics identifies disease mutations conferring important independent prognostic information • Molecular diagnostics are essential to distinguish a sizeable group of patients with favourable prognosis who are unlikely to benefit from routine allografting in 1 st CR • MRD detection can identify patients destined to fail frontline therapy, who may benefit from additional therapy • Embracing new technologies to refine diagnosis and track treatment response is critical for the development of more personalized approaches to AML therapy