Selecting the proper tool for a very precise job
The depth of insight gained from MRD is highly influenced by the capabilities of the measurement tool1-4
MD, Chief Medical Officer of the Leukemia & Lymphoma Society
A peer exchange roundtable discussion about the sensitivity and reproducibility of MRD testing methods.
the ability to detect residual disease even at low levels
- This is usually expressed as a ratio of cancer cells detected among the cells in a sample (eg, 1 cancer cell in 1,000 or 10,000 total cells assessed)
- Patients who are MRD negative at deeper levels of sensitivity have been shown to have improved clinical outcomes
the ability of a test to report accurate and reliable results and to minimize false determinations
- An assay must accurately differentiate between healthy and malignant cells
- An assay should be robust enough to detect changes in cancer cell markers that can occur as a result of newer treatments such as antibody-targeted therapy
the reproducibility of assay results, regardless of the timing, location, or operator of the testing method
- Assay standardization is critical when test results may be used to inform clinical decisions
- Standardization can be assessed in a variety of ways. Regulatory pathways such as FDA clearance and CLIA certification provide verification of whether assays have been standardized
the physical and financial experience patients can expect from testing
- One important consideration is the amount and type of specimen needed for testing, as well as the criteria for sample quality and how easy or difficult the required sample may be to obtain
- Testing costs and insurance coverage also are important, as is the availability of patient support
- Tests should provide clear results that can be shared with patients to guide discussions
The accuracy and sensitivity of MRD testing has evolved over time, keeping pace with advancements in treatment12-14
As therapies for hematologic malignancies advance by becoming more precise and targeted, our assessment of their success also should advance.12-17
As the earliest approach to quantitative disease burden assessment, this technique enabled pathologists to visually evaluate and count cells using a microscope.
- Cellular assessment with limited sensitivity that can range from 1 cancer cell in 20 cells assessed to 1 cancer cell in 100 cells assessed
- Still utilized as an upfront diagnostic tool, but less commonly used post treatment due to limitations in sensitivity and precision
- May not detect subclinical disease burden, which is known to be predictive of recurrence even in the absence of symptoms
New in the 1980s, this cellular assessment looks at cell-surface markers that can change throughout the course of disease.
- Cellular assessment with modest sensitivity that, by conventional flow, can range from 5 cancer cells in 1,000 assessed to 1 cancer cell in 10,000 assessed, when 1,000,000 cells are tested; sensitivity levels with next-generation flow can range from 1 cancer cell in 10,000 assessed to 1 cancer cell in 100,000 assessed, when 1,000,000 cells are tested
- Relatively rapid results (from 1 day)
- Historically difficult to standardize, but recent efforts have been made to improve standardization
- Fresh samples required
- Results may be confounded by current immunotherapies that can alter expression of antigens
Also developed in the 1980s, this molecular assessment method identifies and counts gene rearrangements using patient-specific primers.
- Molecular assessment with high sensitivity that can range from 5 cancer cells in 100,000 cells assessed to 1 cancer cell in 1,000,000 assessed, when 1,000,000 cells are tested
- Time-consuming (turnaround is typically 4 to 5 weeks)
- Difficult to standardize due to being patient specific
- Samples can be fresh or stored
Next-Generation Sequencing (NGS) MRD1,5,18,19,27-29
A molecular assessment method that began in the late 1990s, NGS can identify and count specific malignant cells.
- Molecular assessment with high sensitivity of 1 cancer cell in 1,000,000 cells assessed, when 1,000,000 cells are tested
- Relatively quick turnaround (typically 1 week)
- Easily reproduced within and between patients (standardized)
- Samples can be fresh or stored
- Limited in-hospital availability, but available commercially as a send-out test
Prominent physicians emphasize the importance of MRD testing and its evolving role in hematologic cancer treatment, from prognosis to clinical decision-making.
In selecting an MRD assay, consider factors such as sensitivity, specificity, standardization, sample input volume, and turnaround time.3
Anderson KC, Auclair D, Kelloff GJ, et al. The role of minimal residual disease testing in myeloma treatment selection and drug development: current value and future applications [published online for public access April 20, 2017]. Clin Cancer Res. 2017;23(15):3980-3993. doi:10.1158/1078-0432.CCR-16-2895
Rawstron AC, Gregory WM, de Tute RM, et al. Minimal residual disease in myeloma by flow cytometry: independent prediction of survival benefit per log reduction. Blood. 2015;125(12):1932-1935.
Chen X, Wood BL. How do we measure MRD in ALL and how should measurements affect decisions. Re: treatment and prognosis? Best Pract Res Clin Haematol. 2017;30(3):237-248.
Brüggemann M, Kotrova M. Minimal residual disease in adult ALL: technical aspects and implications for correct clinical interpretation. Blood Adv. 2017;1(25):2456-2466.
Wood B, Wu D, Crossley B, et al. Measurable residual disease detection by high-throughput sequencing improves risk stratification for pediatric B-ALL. Blood. 2018;131(12):1350-1359.
Pulsipher MA, Carlson C, Langholz B, et al. IgH-V(D)J NGS-MRD measurement pre- and early post-allotransplant defines very low- and very high-risk ALL patients. Blood. 2015;125(22):3501-3508.
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Acute Lymphoblastic Leukemia (Version 1.2018). © 2018 National Comprehensive Cancer Network, Inc, website. NCCN.org. Published March 12, 2018. Accessed July 27, 2018.
Saah A, Hoover D. “Sensitivity” and “specificity” reconsidered: the meaning of these terms in analytical and diagnostic settings. Ann Intern Med. 1997;126(1):91-94.
Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical Laboratory Improvements Amendment (CLIA): LDT and CLIA FAQs. Accessed May 10, 2018. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/LDT-and-CLIA_FAQs.pdf.
Department of Health and Human Services, Food and Drug Administration. Food, Drug and Cosmetic Act. https://www.fda.gov /MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/510kClearances/default.htm. Accessed October 10, 2018.
Berry DA, Zhou S, Higley H, et al. Association of minimal residual disease with clinical outcome in pediatric and adult acute lymphoblastic leukemia: a meta-analysis [published online July 13, 2017]. JAMA Oncol. 2017;3(7):e170580. doi:10.1001/jamaoncol.2017.0580
Thompson M, Brander D, Nabhan C, Mato A. Minimal residual disease in chronic lymphocytic leukemia in the era of novel agents: a review. JAMA Oncol. 2018;4(3):394-400.
Brüggemann M, Raff T, Kneba M. Has MRD monitoring superseded other prognostic factors in adult ALL? Blood. 2012;120(23):4470-4481.
Martinez-Lopez J, Lahuerta JJ, Pepin F, et al. Prognostic value of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood. 2014;123(20):3073-3079.
Mailankody S, Korde N, Lesokhin AM, et al. Minimal residual disease in multiple myeloma: bringing the bench to the bedside. Nat Rev Clin Oncol. 2015;12(5):286-295.
Flores-Montero J, Sanoja-Flores L, Paiva B, et al. Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma. Leukemia. 2017;31(10):2094-2103.
Sherrod AM, Hari P, Mosse CA, Walker RC, Cornell RF. Minimal residual disease testing after stem cell transplantation for multiple myeloma. Bone Marrow Transplant. 2016;51(1):2-12.
van Dongen JJM, van der Velden VHJ, Brüggemann M, Orfao A. Minimal residual disease diagnostics in acute lymphoblastic leukemia: need for sensitive, fast, and standardized technologies. Blood. 2015;125(26):3996-4009.
Faham M, Zheng J, Moorhead M, et al. Deep-sequencing approach for minimal residual disease detection in acute lymphoblastic leukemia. Blood. 2012;120(26):5173-5180.
Campana D. Role of minimal residual disease monitoring in adult and pediatric acute lymphoblastic leukemia [published online for public access]. Hematol Oncol Clin North Am. 2009;23(5):1083-1098, vii. doi:10.1016/j.hoc.2009.07.010
Han Y, Gu Y, Zhang AC, Lo YH. Review: imaging technologies for flow cytometry. Lab Chip. 2016;16(24):4639–4647.
Mejstríková E, Hrusak O, Borowitz MJ, et al. CD19-negative relapse of pediatric B-cell precursor acute lymphoblastic leukemia following blinatumomab treatment. Blood Cancer J. 2017;7(12):659.
Wang XM. Advances and issues in flow cytometric detection of immunophenotypic changes and genomic rearrangements in acute pediatric leukemia. Transl Pediatr. 2014;3(2):149-155.
Kawasaki ES, Clark SS, Coyne MY, et al. Diagnosis of chronic myeloid and acute lymphocytic leukemias by detection of leukemia-specific mRNA sequences amplified in vitro. Proc Natl Acad Sci USA. 1988;85(15):5698–5702.
Pongers-Willemse MJ, Verhagen OHM, Tibbe GJM, et al. Real-time quantitative PCR for the detection of minimal residual disease in acute lymphoblastic leukemia using junctional region specific TaqMan probes. Leukemia. 1998;12(12):2006-2014.
Paiva B, van Dongen JJM, Orfao A. New criteria for response assessment: role of minimal residual disease in multiple myeloma. Blood. 2015;125(20):3059-3068.
Kamps R, Brandao RD, Bosch BJ, et al. Next-generation sequencing in oncology: genetic diagnosis, risk prediction and cancer classification. Int J Mol Sci. 2017;18(2), pii:E308. doi:10.3390/ijms18020308
Carlson CS, Emerson RO, Sherwood AM, et al. Using synthetic templates to design an unbiased multiplex PCR assay. Nat Commun. 2013;4:2680.
Reuter J, Spacek DV, Snyder MP. High-throughput sequencing technologies. Mol Cell. 2015;58(4):586-597.