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Flow Cytometry Based MRD and Its Impact on Survival Outcome in Children and Young Adults with ALL: A Prospective Study from a Tertiary Cancer Centre in Southern India

  • Soumya Surath Panda
  • Venkatraman RadhakrishnanEmail author
  • Prasanth Ganesan
  • Rejiv Rajendranath
  • Trivadi S. Ganesan
  • Kamalalayan Raghavan Rajalekshmy
  • Rajesh Kumar Bhola
  • Hemlata Das
  • Tenali Gnana Sagar
Original Article
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Abstract

Presence of minimal residual disease (MRD) following induction chemotherapy is a well-recognized risk factor to predict relapse in acute lymphoblastic leukemia (ALL). There is paucity of data on MRD and outcome in ALL from India. We share our experience in establishing a flow cytometry-based MRD assay for ALL with emphasis on determination of the number of patients who had MRD on day 35 of induction therapy and its correlation with outcome and other prognostic factors. We prospectively studied MRD in patients with ALL less than 25 years who achieved morphological complete remission with induction therapy. The initial series consisted of 104 patients with ALL. Ninety-two patients had bone marrow samples collected on day 35 of remission induction chemotherapy that was adequate for MRD. Strategy of monitoring MRD was based on flow cytometry using six color staining according the leukemia associated immunophenotype found at diagnosis. Data analysis was done using Fisher exact test. The median age was 8.5 years (range 0.9–22 years). Thirty-seven out of ninety-two patients (40.2%) had MRD at end of induction. MRD on day 35 was between 0.01 and 0.1% in 18.9% of patients, between 0.1 and 1% in 59.5% and more than 1% in 21.6% patients. Among the patients who had MRD, 16.7% had favourable cytogenetics, 60% had intermediate and 13.3% had high-risk cytogenetics. The presence or absence of residual leukemia by flow cytometry at day 35 was not significantly related to age (p = 1.0), male gender (p = 0.08) hyperleukocytosis (p = 0.25) or day 8 blast clearance (p = 0.21). However, T cell phenotype (p < 0.001) was significantly associated with MRD. The 5-year event free survival (EFS) for patients who had MRD versus those who did not was 69% and 61.1% respectively (p = 0.41). The 5-year overall survival (OS) for patients who had MRD versus those who did not was 72.5% and 61.1% respectively (p = 0.33). Flow cytometric techniques can be applied to monitor MRD in patients of ALL undergoing induction therapy. Our results suggest MRD correlates with certain known prognostic factors. Though the EFS and OS was lower in MRD positive patients, the results were not statistically significant probably because of the small sample size.

Keywords

Acute lymphoblastic leukemia Flow cytometry Minimal residual disease 

Notes

Funding

The project was funded through an Educational Grant from Dell Inc, USA.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human and Animals Rights

All procedures performed in the study were in accordance with the ethical standards of the institution and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Ward E, DeSantis C, Robbins A et al (2014) Childhood and adolescent cancer statistics. CA Cancer J Clin 64:83PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Arora RS, Arora B (2016) Acute leukemia in children: a review of the current Indian data. South Asian J Cancer 5(3):155–160PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Pui C-H, Mullighan CG, Evans WE, Relling MV (2012) Pediatric acute lymphoblastic leukemia: where are we going and how do we get there? Blood 120(6):1165–1174PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Vidriales M-B et al (2003) Minimal residual disease in adolescent (older than 14 years) and adult acute lymphoblastic leukemias: early immunophenotypic evaluation has high clinical value. Blood 101(12):4695–4700PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Campana D (2009) Role of minimal residual disease monitoring in adult and pediatric acute lymphoblastic leukemia. Hematol Oncol Clin N Am 23(5):1083–1098CrossRefGoogle Scholar
  6. 6.
    Brüggemann M, Raff T, Kneba M (2012) Has MRD monitoring superseded other prognostic factors in adult ALL? Blood 120(23):4470–4481PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Ryan J et al (2009) Minimal residual disease detection in childhood acute lymphoblastic leukaemia patients at multiple time-points reveals high levels of concordance between molecular and immunophenotypic approaches. Br J Haematol 144(1):107–115PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Gaipa G et al (2012) Time point-dependent concordance of flow cytometry and real-time quantitative polymerase chain reaction for minimal residual disease detection in childhood acute lymphoblastic leukemia. Haematologica 97(10):1582–1593PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Borowitz MJ et al (2008) Clinical significance of minimal residual disease in childhood acute lymphoblastic leukemia and its relationship to other prognostic factors: a Children’s Oncology Group study. Blood 111(12):5477–5485PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Bene M et al (1995) Proposals for the immunological classification of acute leukemias. European Group for the Immunological Characterization of Leukemias (EGIL). Leuk Off J Leuk Soc Am Leuk Res Fund UK 9:1783–1786Google Scholar
  11. 11.
    van Dongen JJ et al (1998) Prognostic value of minimal residual disease in acute lymphoblastic leukaemia in childhood. Lancet Lond Engl 352(9142):1731–1738CrossRefGoogle Scholar
  12. 12.
    Irving J et al (2009) Establishment and validation of a standard protocol for the detection of minimal residual disease in B lineage childhood acute lymphoblastic leukemia by flow cytometry in a multi-center setting. Haematologica 94:870–874PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Madzo J et al (2003) Slower molecular response to treatment predicts poor outcome in patients with TEL/AML1 positive acute lymphoblastic leukemia: prospective real-time quantitative reverse transcriptase-polymerase chain reaction study. Cancer 97(1):105–113PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Steenbergen EJ et al (1997) Rearrangement status of the malignant cell determines type of secondary IgH rearrangement (V-replacement or V to DJ joining) in childhood B precursor acute lymphoblastic leukemia. Leukemia 11(8):1258–1265PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Gruhn B et al (1998) Minimal residual disease after intensive induction therapy in childhood acute lymphoblastic leukemia predicts outcome. Leukemia 12(5):675–681PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Willemse MJ, Seriu T, Hettinger K et al (2002) Detection of minimal residual disease identifiesdifferences in treatment response between T-ALL and precursor B-ALL. Blood 99:4386PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Eckert C, von Stackelberg A, Seeger K et al (2013) Minimal residual disease after induction isthe strongest predictor of prognosis in intermediate risk relapsed acute lymphoblasticleukaemia–long-term results of trial ALL-REZ BFM P95/96. Eur J Cancer 49:1346PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Eckert C, Henze G, Seeger K et al (2013) Use of allogeneic hematopoietic stem-cell transplantation based on minimal residual disease response improves outcomes for children with relapsed acute lymphoblastic leukemia in the intermediate-risk group. J Clin Oncol 31:2736PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Vora A, Goulden N, Wade R et al (2013) Treatment reduction for children and young adults withlow-risk acute lymphoblastic leukaemia defined by minimal residual disease (UKALL 2003): arandomised controlled trial. Lancet Oncol 14:199PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Knechtli CJ, Goulden NJ, Hancock JP et al (1998) Minimal residual disease status before allogeneicbone marrow transplantation is an important determinant of successful outcome for children andadolescents with acute lymphoblastic leukemia. Blood 92:4072PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Uzunel M, Mattsson J, Jaksch M et al (2001) The significance of graft-versus-host disease andpretransplantation minimal residual disease status to outcome after allogeneic stem celltransplantation in patients with acute lymphoblastic leukemia. Blood 98:1982PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Goulden NJ, Knechtli CJ, Garland RJ et al (1998) Minimal residualdisease analysis for the prediction of relapse in children withstandard-risk acute lymphoblastic leukaemia. Br J Haematol 100:235PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Kuang S, Gu L, Dong S et al (1996) Long-term follow-up of minimalresidual disease in childhood acute lymphoblastic leukemiapatients by polymerase chain reaction analysis of multiple clone-specific or malignancy-specific gene markers. Cancer Genet Cytogenet 88:110PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Pui C-H et al (2009) Treatment of childhood acute lymphoblastic leukemia without prophylactic cranial irradiation. N Engl J Med 360(26):2730–2741PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Foroni L, Coyle LA, Papaioannou M et al (1997) Molecular detection ofminimal residual disease in adult and childhood acutelymphoblastic leukaemia reveals differences in treatmentresponse. Leukemia 11:1732PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Campana D, Coustan-Smith E, Janossy G (1990) The immunologicdetection of minimal residual disease in acute leukemia. Blood 76:163PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Wells DA, Sale GE, Shulman HM et al (1998) Multidimensional flowcytometry of marrow can differentiate leukemic from normallymphoblasts and myeloblasts after chemotherapy and bonemarrow transplantation. Am J Clin Pathol 110:84PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Dworzak MN et al (2002) Prognostic significance and modalities of flow cytometric minimal residual disease detection in childhood acute lymphoblastic leukemia. Blood 99(6):1952–1958PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Coustan-Smith E et al (2002) Prognostic importance of measuring early clearance of leukemic cells by flow cytometry in childhood acute lymphoblastic leukemia. Blood 100(1):52–58PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Coustan-Smith E, Behm FG, Sanchez J et al (1998) Immunologicaldetection of minimal residual disease in children with acutelymphoblastic leukaemia. Lancet 351:550PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Coustan-Smith E et al (2000) Clinical importance of minimal residual disease in childhoodacute lymphoblastic leukemia. Blood 96(8):2691–2696PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Basso G et al (2009) Risk of relapse of childhood acute lymphoblastic leukemia is predicted by flow cytometric measurement of residual disease on day 15 bone marrow. J Clin Oncol Off J Am Soc Clin Oncol 27(31):5168–5174CrossRefGoogle Scholar
  33. 33.
    Jmili NB et al (2010) Flow cytometry evaluation of minimal residual disease in acute lymphoblastic leukaemia type B. Open Leuk J 3(1):47–54Google Scholar
  34. 34.
    Möricke A et al (2008) Risk-adjusted therapy of acute lymphoblastic leukemia can decrease treatment burden and improve survival: treatment results of 2169 unselected pediatric and adolescent patients enrolled in the trial ALL-BFM 95. Blood 111:4477–4489PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    A. Sharma et al. (2013) Clinical features and outcome of B-cell acute lymphoblastic leukemia in patients older than 9 years: a single center experience of 241 cases from AIIMS, New Delhi, India. J Clin Oncol 31(15-suppl): 7082–7082Google Scholar
  36. 36.
    Gruhn B et al (1998) Minimal residual disease after intensive induction therapy in childhood acute lymphoblastic leukemia predicts outcome. Leukemia 12(5):675–681PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Rajalekshmy KR, Abitha AR, Pramila R, Gnanasagar T, Maitreyan V, Shanta V (1994) Immunophenotyping of acute lymphoblastic leukaemia in Madras, India. Leuk Res 18(3):183–190PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Advani S et al (1999) Acute lymphoblastic leukemia in India: an analysis of prognostic factors using a single treatment regimen. Ann Oncol 10(2):167–176PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Borowitz MJ et al (2015) Prognostic significance of minimal residual disease in high risk B-ALL: a report from Children’s Oncology Group study AALL0232. Blood 126(8):964–971PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Wood BL et al (2014) T-lymphoblastic leukemia (T-ALL) shows excellent outcome, lack of significance of the early thymic precursor (ETP) immunophenotype, and validation of the prognostic value of end-induction minimal residual disease (MRD) in Children’s Oncology Group (COG) Study AALL0434. Blood 124(21):1CrossRefGoogle Scholar
  41. 41.
    Schrappe M, Valsecchi MG, Bartram CR et al (2011) Late MRD response determines relapse risk overall and in subsets of childhood T-cell ALL: results of the AIEOP-BFM-ALL 2000 study. Blood 118:2077–2084PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Singh N, Agrawal N, Sood R et al (2019) T-ALL minimal residual disease using a simplified gating strategy and its clinico-hematologic correlation: a single center experience from North India. Indian J Hematol Blood Transfus.  https://doi.org/10.1007/s12288-019-01106-9 CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Berry DA et al (2017) Association of Minimal residual disease with clinical outcome in pediatric and adult acute lymphoblastic leukemia: a metaanalysis. JAMA Oncology 3:e170580PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Indian Society of Hematology and Blood Transfusion 2019

Authors and Affiliations

  • Soumya Surath Panda
    • 2
  • Venkatraman Radhakrishnan
    • 1
    Email author
  • Prasanth Ganesan
    • 1
  • Rejiv Rajendranath
    • 1
  • Trivadi S. Ganesan
    • 1
  • Kamalalayan Raghavan Rajalekshmy
    • 1
  • Rajesh Kumar Bhola
    • 2
  • Hemlata Das
    • 2
  • Tenali Gnana Sagar
    • 1
  1. 1.Departments of Medical OncologyCancer Institute (WIA)Adyar, ChennaiIndia
  2. 2.Department of Medical OncologyIMS and SUM Hospital, Siksha O Anusandhan UniversityBhubaneswarIndia

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