Overview of hot topics in flow cytometry. in acute leukemia. ISLH Milan, May 2016 MC Béné

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Joella Julia Boone
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1 Overview of hot topics in flow cytometry including MRD in acute leukemia ISLH Milan, May 2016 MC Béné

2 No conflicts of interest

3 Morphology &Flow cytometry Settled technologies Somehow taken for granted Yet, getting more and more automated Digitalized imaging HIV follow-up CBC instruments

5 Flow cytometry still a multifaceted versatile tool Instruments : 4 to 12 parameters and growing Antibody combinations Lab-based Many consensus-based proposals Financial limitations Recruitement-based limitations Commercial solutions Custom-made panels Ready-to-use mixes Liquid (vials) «Dry» tubes Analysis software Imagination rules!

6 Bone marrow cartography Arnoulet et al. Cytometry B 2009 Identification of mature cells Boolean definition of progenitors: «NOT lymphocytes AND NOT monocytes AND NOT granulocytes» GTLLF «bermudes»

7 The CD45 scattergram GTLLF Stetler Stevenson Stachursky Xu Cherian Wood

8 STANDARDIZATION HARMONIZATION

9 Euroflow : the idea Standardize instruments Find the best antibodies Fix panels Van Dongen et al, 2012, Leukemia Overall a good idea A lot of work A lot of money.

10 Pros and cons Comprehensive of most hematological malignancies Some good display ideas Files merge for comparison Complex backbones Complex displays Blackbox of the PCA analysis and APS presentation Expensive to apply

11 Comprehensive Berlin handout 2009 Final version 2012

12 A lot of markers an interesting display

13 Confusing representations

14 HARMONEMIA A universal strategy for comparing flow cytometry immunophenotyping data obtained from instruments of different make Lysed unstained blood : no more than 15-20% cells in the first channel for each color determination of PMT voltages Lacombe et al, 2016, Leukemia

15 Unlabeled cells

16 120 Normalized target channel for beads on 23 instruments

17 Merging example Next step : atlas of 8/10 colors normal bone marrow

18 Routine samples in 22 configurations PMN CD11b A Mo CD11b B PMN CD16 C Mo CD33 D

19 ACUTE LEUKEMIA AND MINIMAL RESIDUAL DISEASE Pubmed ~2900 papers +Flow cytometry ~600 papers

20 Flow cytometry and acute leukemia Essential for diagnosis/classification Lineage assignment and blockade stage AML with minimal differentiation Myelomonocytic lineage MPAL (mixed phenotype acute leukemia) Morphology and flow cytometry for rapid early orientation of patients management Follow-up: MRD

21 How to find the «bad» cells? The candy jar concept Morphology Cytogenetics Flow cytometry Molecular probes Clinical relevance Size Shape Colour Smell Taste

22 General principles Specificities of acute leukemia Constant medullary involvement Frequent peripheral involvement Fast evolution Of the disease Of answer to therapy Of relapses Cellular specificities Molecular (DNA, RNA) Immunophenotypic : leukemia associated immunophenotype LAIP

23 Immunophenotypic detection of MRD Immunophenotypic anomalies of blasts Aberrant expression on leukemic cells Decreased expression Hyperexpression Asynchronism Lineage infidelity Notion of Leukemia Associated ImmunoPhenotype (LAIP) Immunophenotypes absent on normal cells Notion of «empty gate»

24 Recent american survey Keeney et al. 2016, Arch Pathol Lab Med Questionnaire to 549 laboratories 500 answers (91%) 33% 67% ALL AML CLL MM Other

25 Threshold? In this survey : 10-3 to 10-5??? Number of cells counted? Number of parameters? Expected population of abnormal cells? 10? 20? 50? None!?

26 Limits of MRD detection Appropriate diagnostic panels Fresh cells Number of cells available Necessary limited in aplastic patients Conditions sensitivity (clusters) Conditions the number of informative combinations Remain pragmatic! 10-4 = 1/10000 cells = 10/100000

27 The phases of MRD

28 CD16 CD16 Application to peripheral blood in AML induction 100 Lacombe et al, 2009, Leukemia CD11b CD11b Boolean definition of blast cells

29 CD16 Sequential daily assessment D0 5.3% 100 D1 3.9% 73.7 D2 1.1% 21.2 CD11b D3 D4 0.5% % log decrease : 90% BDR

30 EFS probability (%) Prognostic value BDR (slope) BDR90 D D >D Time (days) Time (days)

31 DFS probability (%) Also stratifies intermediate risk cytogenetics 100 Karyotype I 100 Karyotype N BDR (D90) 20 BDR (D90) CR (days) CR (days)

32 Applicable to automated flow Hematoflow Diagnosis D0

33 Chemotherapy D1

34 Chemotherapy D2

35 Chemotherapy D3

36 Chemotherapy D4

37 MRD IN ACUTE LYMPHOBLASTIC LEUKEMIA

38 Campana, 1999 First studies in the early 1990 Empty spaces of normal bone marrow

39 Gaipa G et al. 2013, Cyometry B

40 ccd3 CD7 CD7 CD2 CD2 CD19 CD45 CD58 CD58 CD33 Fossat et al. 2015, Cytometry B CD45+CD19+ CD10+ CD19+ CD10+ CD19+ CD10+ CD19+ CD10+ SSC CD10 CD24 CD38 CD10 ccd3+ ccd3+ ccd3+ ccd3+ SSC scd3 CD2 CD99 ntdt

41 Karawajew et al Haematologica CD58 CD10 CD19 CD34 CD22 CD20 Syto41 CD45 CD38 CD10 CD19 CD34 CD22 CD20 Syto41 CD45 Sensitivity Specificity Correlation with PCR CD % CD %

42 Regenerating bone marrow: normal spaces, changed proportions Karawajew et al, 2015, Haematologica Van Dongen et al, 2015, Blood

43 Incidence on outcome < >10-2 Basso et al, 2009, JCO 815 Patients Day 15 p< Eveillard et al, 2015, Hem Oncol 123 Patients Day 21 neg-neg pos-neg pos-pos p= Eveillard et al. 2015, Hem Oncol FCM Day 21 vs PCR Day 35

44 Pui et al MRD driven therapy D19

45 MRD IN ACUTE MYELOBLASTIC LEUKEMIA

46 MRD and prognosis of MRD in AML Perea et al. Leukemia 2006 Kern et al. Blood 2004

47 HOVON experience Terwijn M et al. JCO, 2013 Screening panel CD34 CD22 CD45 CD117 CD15 CD13 CD45 CD14 DR CD33 CD45 CD11b CD2 CD56 CD45 CD7 CD36 CD133 CD45 CD19 Mature blasts Overexpression Lack Cross-lineage Asynchronous

48 Molecular complexity MLL-PTD NPM1 FLT3 CEBPA

49 Molecular MRD status provides the most powerful prognostic factor in NPM1 mutant AML NCRI AML17: PCR status in peripheral blood post-chemotherapy course 2 Cumulative Incidence of Relapse MRD +ve 83% Overall Survival MRD neg 77% 2P< MRD neg 28% 2P< % MRD +ve In multivariate analysis MRD status was only significant independent prognostic factor, considering: Age WBC Mutational profile (51 gene panel including FLT3-ITD, DNMT3A, WT1) Ivey A, et al. NEJM 2016

50 Immunophenotypic complexity CD34 CD117 CD33 CD13 CD34 CD117 CD33 CD13

51 MRD a new strategy for AML Boolean equation established at diagnosis A B C D E F MRD = (NOT A) AND (NOT B) AND (NOT C) AND (NOT D) AND (NOT E) AND (NOT F)

52 Diagnosis

53 Importance of the notion of cluster

56 Incidence on outcome

57 Chen et al., 2014 JCO Three 10 colors tubes. Any detectable level considered positive. Median positves : 1% (range %

58 Take home messages MRD feasible in flow cytometry Rapid and available at bedside Current significant threshold <10-4 lower than 10-5 easily accessible when no event is detected If events detected 10 to 20 Early response is the key!

59 Acknowlegements GEIL EGIL ELN WP10 EHA SWG Diagnostics

Subtypes of AML follow branches of myeloid development, making the FAB classificaoon relaovely simple to understand.

Subtypes of AML follow branches of myeloid development, making the FAB classificaoon relaovely simple to understand. 1 2 3 4 The FAB assigns a cut off of 30% blasts to define AML and relies predominantly on morphology and cytochemical stains (MPO, Sudan Black, and NSE which will be discussed later). Subtypes of AML follow