New IMWG Response Criteria Shaji Kumar, M.D. Professor of Medicine Division of Hematology Mayo Clinic Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida Mayo Clinic College of Medicine Mayo Clinic Comprehensive Cancer Center
Limitations of current criteria
Response depth and outcome Diagnosis Depth of response MR PR VGPR ncr CR scr Cure? Time to disease progression CR, complete response; MR, minor response; MRD, minimal residual disease; ncr, near complete response; PR, partial response; scr, stringent complete response; VGPR, very good partial response
Therapy and depth of response 100 80 ORR VGPR CR/nCR 120 100 97 KRd Percentage 60 40 20 Percentage Proportion 80 60 40 20 72 55 39 0 VAD TD RD PAD VTD CVD RVD CVRD Induction regimen CR, complete response; CVD, cyclophosphamide, bortezomib, and dexamethasone; CVRD, bortezomib, dexamethasone, cyclophosphamide and lenalidomide; KRd, carfilzomib, lenalidomide and dexamethasone; ncr, near complete response; ORR, overall response rate; PAD, bortezomib, doxorubicin, and dexamethasone; PR, partial response; RD, lenalidomide and dexamethasone; RVD, lenalidomide, bortezomib and dexamethasone; scr, stringent complete response; TD, thalidomide and dexamethasone; VAD, vincristine, doxorubicin and dexamethasone; VGPR, very good partial response; VTD, bortezomib, thalidomide, and dexamethasone Stewart KA, et al. Blood 2009;114:5436 43; Jakubowiak AJ, et al. Blood 2012;120:1801 9. 0 PR VGPR CR scr
Transitioning from conventional CR Complete Response (CR) Negative serum and urine immunofixation <5% PCs in marrow Stringent Complete Response (scr) Normal FLC ratio No clonal plasma cells in marrow MRD negative Flow negative MRD Sequencing negative MRD Imaging negative MRD
How do we define MRD negativity? The tools: Flow cytometry NextGen sequencing Imaging
Depth of response and outcome PFS OS Time to progression (%) 100 80 60 40 20 0 Median: 80 Median: 45 Median: 27 0 50 100 Time (months) 0.003 0.002 <0.001 150 Survival (%) 100 80 60 40 20 0 0 50 Median: NR Median: NR Median: 55 100 Time (months) 0.3 0.02 0.002 150 MRD <10-5 (n=30) MRD+ 10-3 10-5 (n=37) MRD+ >10-3 (n=43) Martinez-Lopez J, et al. Blood 2014;123:3073 9. NR, not reached; OS, overall survival; PFS, progression free survival
Deeper response better outcome 100 100 Progression-free survival (%) 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 Time (years) Rawstron AC, et al. Blood 2015;125:1932 5. Overall survival (%) 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 <0.01% (N=247) 0.01 <0.1% (N=49) 0.1 <1% (N=72) 1 10% (N=26) 10% (N=3) Time (years)
MRD after novel combinations VRD induction VRD or HDT consolidation VRD consolidation Len maintenance for 1 year Patients without progression (%) 1.0 0.8 0.6 0.4 0.2 0.0 MRD at pre-maintenance P-value : p<0.0001 Negative (<10-6 ) Negative (<10-6) Positive Positive 1.0 0.8 0.6 0.4 0.2 P<0.0001 0.0 0 6 12 18 24 30 36 42 48 Time since randomization (months) P<0.0001 MRD at post-maintenance Negative (<10-6 ) P-value : p<0.0001 Negative (<10-6) Positive Positive 0 6 12 18 24 30 36 42 48 Time since randomization (months) Avet-Loiseau et al. Blood 2015;126:191. HDT, high-dose therapy; Len, lenalidomide; VRD, bortezomib, lenalidomide and dexamethasone
Role of imaging
Post-induction PET Elena Zamagni et al. Blood 2011;118:5989-5995 2011 by American Society of Hematology
Post ASCT PET Elena Zamagni et al. Blood 2011;118:5989-5995 2011 by American Society of Hematology
PET-CT normalisation Premaintenance: PFS 69% 51.6% p < 0.001
PET-CT normalisation Premaintenance: OS 94.6% 69.9% p = 0.003
PET and Flow negative: PFS 89.6% 54.5% p = 0.02
Durability of response 100 TT2 overall survival by 3-year CR status 80 Percentage 60 40 20 0 P-values: a vs b <0.001 a vs c <0.001 b vs c <0.001 0 2 4 6 Years from 3-year landmark after enrolment Deaths/N 5-year estimate (%) a) sus CR 38/258 82 b) non CR 78/218 59 c) los CR 27/37 24 Log-rank P-value <0.0001 8 Hoering A, et al. Blood 2009;114:1299 305.
Revised IMWG response criteria IMWG MRD negativity criteria Response subcategory (Requires complete response as originally defined) Sustained MRDnegative Flow MRDnegative Sequencing MRDnegative Imaging + MRDnegative Response criteria MRD ve in the marrow (next-generation flow cytometry [NGFC] and/or next-generation sequencing [NGS]) and by imaging as defined below, confirmed one year apart. Subsequent evaluations can be used to further specify the duration of negativity Absence of phenotypically aberrant clonal plasma cells by NGFC on bone marrow aspirates using the EuroFlow standard operation procedure for MRD detection in MM (or validated equivalent method) with a minimum sensitivity of 1 in 10 5 nucleated cells or higher Absence of clonal plasma cells by NGS on bone marrow aspirates in which presence of a clone is defined as less than two identical sequencing reads obtained after DNA sequencing of bone marrow aspirates using the Lymphosight platform (or validated equivalent method) with a minimum sensitivity of 1 in 10 5 nucleated cells or higher MRD negative as defined by NGF or NGS PLUS Disappearance of every area of increased tracer uptake found at baseline or a preceding PET/CT or decrease to < mediastinal blood pool SUV or decrease to less than that of surrounding normal tissue Kumar S, et al. Lancet Oncol; in press. CT, computed tomography; IMWG, International Myeloma Working Group; MM, multiple myeloma; PET, positron emission tomography; SUV, standard uptake value
Endpoints Endpoint TTP PFS EFS DFS DOR Definition Duration from start of treatment to disease progression, with deaths from causes other than progression censored. Duration from start of the treatment to disease progression or death (regardless of cause of death), whichever comes first. The definition for EFS depends on how event is defined. In many studies, the definition of EFS used is the same as PFS. EFS may include additional events that are considered to be of importance besides death and progression, including serious drug toxicity. Duration from the start of MRD negativity to the time of reappearance of MRD. DFS applies only to patients in MRD negative state. Duration from first observation of PR to the time of disease progression, with deaths from causes other than progression censored.* Duration of MRD, CR and PR should each be reported as appropriate.
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