REGULAR ARTICLE

Prognostic impact of complete remission with MRD negativity in patients

with relapsed or refractory AML

Nicholas J. Short,1,* Hind Rafei,2,* Naval Daver,1 Hyunsoo Hwang,3 Jing Ning,3 Jeffrey L. Jorgensen,4 Tapan M. Kadia,1
Courtney D. DiNardo,1 Sa A. Wang,4 Elias Jabbour,1 Uday Popat,5 Betul Oran,5 Jorge Cortes,1 Marina Konopleva,1 Musa Yilmaz,1
Ghayas C. Issa,1 Hagop Kantarjian,1 and Farhad Ravandi1

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1
Department of Leukemia, 2Division of Cancer Medicine, 3Department of Biostatistics, 4Department of Hematopathology, and 5Department of Stem Cell Transplantation &
Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX

In relapsed/refractory acute myeloid leukemia (AML), the prognostic impact of complete

Key Points
remission (CR) and measurable residual disease (MRD) negativity is not well established. We
• In relapsed/refractory retrospectively analyzed 141 patients with relapsed/refractory AML who received first
AML, CR and MRD salvage therapy and had MRD assessed by multiparameter flow cytometry at the time of
negativity are associ-
response. Patients who achieved CR with full hematologic recovery as best response vs those
ated with lower risk of
with incomplete hematology recovery had lower cumulative incidence of relapse (P 5 .01)
relapse and better
and better relapse-free survival (P 5 .004) but not overall survival (P 5 .15); a similar trend
relapse-free survival.
was observed in patients who achieved MRD negativity vs those who were MRD positive
• Patients who under- (P 5 .01, P 5 .05, and P 5 .21, respectively). By multivariate analysis, CR and MRD negativity
went HSCT in second
were each independently associated with lower cumulative incidence of relapse (P 5 .001 and
remission had the best
P 5 .003, respectively) and better relapse-free survival (P , .001 and P 5 .02) but not overall
outcomes, irrespective
survival. Patients who achieved CR with MRD negativity had the lowest rates of relapse and best
of hematologic or MRD
survival (2-year overall survival rate, 37%), which was driven largely by lower rates of early
response.
relapse and an increased ability in this group to undergo hematopoietic stem cell transplantation
(HSCT); however, post-HSCT outcomes were similar regardless of response to salvage
chemotherapy. Overall, in patients with relapsed/refractory AML, CR with MRD negativity was
associated with the best outcomes, supporting it as the optimal response in this setting.

Introduction

Acute myeloid leukemia (AML) is a heterogeneous disease, with widely variable disease biology and
response to conventional therapies.1 Although cytogenetics and gene mutations are among the primary
disease-related factors that influence prognosis,2 how well the disease responds to initial therapy is also
a vital determinant of long-term outcomes and provides useful information about the chemosensitivity of
an individual’s leukemia that cannot necessarily be predicted from pretreatment characteristics.3 In the
frontline setting, the achievement of complete remission (CR) with full hematologic recovery has been
shown to confer better long-term outcomes than morphologic remission (ie, ,5% bone marrow blasts)
with incomplete peripheral blood count recovery.4,5 Among patients who achieve morphologic
remission, assessment of measurable (or “minimal”) residual disease (MRD) also provides important
prognostic information, and multiple studies have shown that the achievement of MRD negativity is
a strong predictor of better long-term outcomes in patients with AML undergoing frontline therapy.6-15
Because achievement of CR and MRD negativity are both independently associated with lower
rates of relapse and superior survival in the frontline setting,5 recent consensus guidelines have supported

Submitted 29 June 2020; accepted 30 October 2020; published online 10 December Requests for data sharing may be submitted to the corresponding author (Nicholas
2020. DOI 10.1182/bloodadvances.2020002811. J. Short; e-mail: [email protected]).
The full-text version of this article contains a data supplement.
*N.J.S. and H.R. contributed equally to this study. © 2020 by The American Society of Hematology

22 DECEMBER 2020 x VOLUME 4, NUMBER 24 6117

the use of a new response criterion: “CR without MRD” (CRMRD–).16 previously described.23,24 When available, the phenotypic profiles
CRMRD– is now considered the optimal response in AML, although, of pretreatment blasts were compared with those of specimens
notably, the data supporting this recommendation are based almost submitted for MRD testing. A distinct cluster of at least 20 cells
exclusively on studies in the frontline setting, and its applicability to showing altered expression of $2 antigens was regarded as an
patients with relapsed/refractory disease is largely unknown. aberrant population. The sensitivity of this assay is 0.1% or higher. All
specimens with unequivocally positive results were included in this
For patients with AML in first relapse, established prognostic factors
analysis. However, specimens with indeterminate MRD assessment
include: cytogenetics at diagnosis, prior allogeneic hematopoietic
or with negative results but suboptimal cell counts were excluded.
stem transplantation (HSCT), age at relapse, and length of relapse-
free interval after first relapse.17 Together, these factors can stratify Response and outcome definitions
patients into widely disparate risk groups, with 5-year overall survival
CR, CRi, and MLFS were defined according to European LeukemiaNet
(OS) rates ranging from 4% to 46%. Although it may be reasonably
consensus guidelines.16 The best response achieved within 1 to 2
assumed that the posttreatment factors which influence prognosis

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cycles of first salvage chemotherapy was used for this analysis.
in the frontline setting would translate to patients with relapsed/
Relapse was defined as recurrence of bone marrow blasts .5%
refractory AML, to our knowledge, neither the role of hematologic
or extramedullary AML. Cumulative incidence of relapse (CIR) was
recovery or achievement of MRD negativity at time of response has
calculated from the time of best response until relapse, censored
been systematically evaluated in the salvage setting, with the
for death in morphologic remission, or if the patient was alive at
exception of a few small studies of specific novel agents.18-21 To
last follow-up. Relapse-free survival (RFS) was calculated from
evaluate the relevance of the response criteria of CRMRD– in
the time of best response until relapse or death from any cause,
patients with relapsed/refractory AML, we performed a retrospective
censored if the patient was alive at last follow-up. OS was
study evaluating the impact of hematologic recovery and achieve-
calculated from the time of treatment initiation until death from
ment of MRD negativity in patients receiving first salvage therapy
any cause, censored if the patient was alive at last follow-up.
with an intensive chemotherapy regimen. We also sought to
Survival estimates were not censored at the time of HSCT.
determine how receiving subsequent HSCT might influence the
prognostic impact of these responses. Statistical methods
Methods Patient characteristics were summarized by using median (range) for
continuous variables and frequencies (percentages) for categorical
Study design and participants variables. To compare 2 groups, Fisher’s exact test was performed
This retrospective study evaluated the prognostic impact of for categorical variables, and the Wilcoxon rank sum test was
hematologic recovery and MRD status in adults with relapsed or performed for continuous variables. Univariate Cox proportional
refractory AML receiving first salvage therapy. Refractoriness to hazards models were used to evaluate the risk factors associated
first-line therapy was defined as lack of response to at least 1 cycle with survival outcomes. A multivariate proportional hazards model
of intensive induction chemotherapy or at least 2 cycles of lower was obtained by first including the factors with P , .20 on univariate
intensity therapy (unless clear evidence of disease progression after analysis and then finalizing via backward elimination until all remaining
1 cycle). To be eligible for this analysis, patients were required to factors had P , .05. Subgroup analysis was performed for
have achieved CR, CR with incomplete hematologic recovery (CRi), transplanted patients and nontransplanted patients; the survival
or morphologic leukemia-free status (MLFS) within 1 to 2 cycles of outcomes for transplanted patients were redefined from the time
first salvage regimen and have an evaluable MRD measurement at the of HSCT. Landmark analysis was conducted for nontransplant
time of best response. To reduce heterogeneity among treatment patients using landmark time of 1.4 months, which was the median
regimens, only patients who received an intermediate- or high-dose time to HSCT among patients undergoing transplant. Statistical
cytarabine-based salvage regimen (defined as a cumulative dose of analyses were conducted in R version 3.5.1.
cytarabine $700 mg/m2 with re-induction) were included in the analysis.
The various salvage regimens used are shown in supplemental Results
Table 1. Patients with core-binding factor AML were excluded, as Patient characteristics and study cohort
these patients are commonly evaluated with polymerase chain
reaction–based MRD assays as standard of care.22 Between August 2011 and July 2018, we identified 192 patients
with relapsed/refractory AML who achieved CR/CRi/MLFS after
This study was conducted at a single academic center (The first salvage therapy. Fifty-one patients were excluded due to no
University of Texas MD Anderson Cancer Center), and it was available MRD information (n 5 30), equivocal MRD assessment
approved by the institutional review board of the center. All patients (n 5 20), and extramedullary disease only (n 5 1). Overall, 141
provided informed consent according to institutional guidelines and patients with relapsed or refractory AML met inclusion criteria and
the Declaration of Helsinki. were included in this analysis. Baseline characteristics of the study
population are shown in Table 1. The median age was 58 years
MRD assessment (range, 17-84 years). For first-line therapy, 90 patients (64%)
MRD was assessed by 8-color multiparameter flow cytometry (MFC) received intensive cytotoxic chemotherapy, and 51 patients (36%)
as previously described.6 Briefly, MRD assessment by MFC was received lower intensity therapy, primarily with a hypomethylating
performed on whole bone marrow specimens. Data were acquired agent. Eighty-eight patients (62%) were refractory to induction
for at least 2 3 105 cells when permitted by the specimen’s quality. therapy or had a first remission duration ,1 year. Among 80
MRD was identified compared with the known patterns of antigen patients who had responded to frontline therapy and in whom the
expression by normal maturing myeloid precursors and monocytes as duration of first response was known, 42 (53%) had a first remission

6118 SHORT et al 22 DECEMBER 2020 x VOLUME 4, NUMBER 24

Table 1. Patient characteristics Eighty-six patients (61%) achieved MRD negativity at the time of
Characteristic Value (N 5 141) best response. Best response was CRMRD– in 61 patients (43%),
CR with MRD positivity in 34 patients (24%), CRi with MRD
Age, y 58 [17-84]
negativity in 12 patients (9%), CRi with MRD positivity in 14 patients
WBC, 3109/L 2.3 [0.3-207.0]
(10%), MLFS with MRD negativity in 13 patients (9%), and MLFS
Hemoglobin, g/dL 9.6 [3.8-14.3] with MRD positivity in 7 patients (5%). Notably, the rates of MRD
Platelets, 3109/L 43 [3-464] negativity among patients achieving CR, CRi, and MLFS were not
BM blasts, % 32 [1-91] significantly different (64%, 46%, and 65%, respectively; P 5 .22),
Cytogenetics
suggesting a lack of association between hematologic recovery and
MRD response. Among MRD-positive patients, 53 had a quantifiable
Diploid 59 (42)
MRD value. MRD levels at best response were ,0.1% in 4 patients
Poor risk 38 (27) (8%), 0.1% to 0.99% in 27 patients (51%), and $1% in 22 patients

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Others 42 (30) (42%). There was no difference in median level of MRD for
Insufficient metaphases/not done 2 (1) patients who achieved CR, CRi, or MLFS (0.66%, 0.70%, and
CR1 response 1.50%; P 5 .68).
Refractory or CR1 duration ,1 y 88 (62) Factors associated with hematologic recovery and
CR1 duration $1 y 38 (27) MRD status
Unknown 15 (11)
Predictors for achievement of CR (vs CRi/MLFS) included diploid
Prior HSCT 13 (9) karyotype (78% vs 59% for patients with non-diploid karyotype;
2 cycles to best response 19 (13) P 5 .02) and first remission duration $1 year (87% vs 57% for
Mutations* patients who were refractory to frontline therapy or with first
NPM1 22/57 (39)
remission duration ,1 year; P 5 .001) (supplemental Table 2).
Higher pretreatment bone marrow percentage was associated with
NRAS/KRAS 15/64 (23)
a significantly increased rate of MRD negativity (median bone
IDH2 16/79 (20)
marrow blast percentage for MRD-negative vs MRD-positive cases,
IDH1 14/79 (18) 35% vs 26%; P 5 .03) (supplemental Table 3). However,
ASXL1 11/61 (18) achievement of MRD negativity was not associated with any other
TET2 9/62 (15) pretreatment parameter.
FLT3-ITD 12/85 (14) Outcomes by hematologic recovery and MRD status
DNMT3A 10/71 (14) for the entire cohort
CEBPA 9/69 (13)
Given the similar outcomes for patients with CRi and MLFS in this
RUNX1 8/62 (13) cohort, these patients were combined for survival analyses. Patients
WT1 6/61 (10) who achieved CR vs CRi/MLFS had significantly lower CIR (hazard
PTPN11 6/68 (9) ratio [HR], 0.55; 95% confidence interval [CI], 0.34-0.88; P 5 .01)
FLT3-TKD 7/85 (8) (Figure 1A) and better RFS (HR, 0.54; 95% CI, 0.35-0.82;
P 5 .004) (Figure 1B) but not OS (HR, 0.72; 95% CI, 0.46-1.12;
EZH2 5/67 (7)
P 5 .15) (Figure 1C). A similar trend was observed in patients who
GATA2 4/62 (6)
achieved MRD negativity vs those who were MRD positive (CIR HR,
Continuous variables are listed as median [range] and categorical variables as n (%) or 0.55 [95% CI, 0.35-0.85; P 5 .01]; RFS HR, 0.67 [95% CI,
n/N (%). 0.45-0.99; P 5 .05]; OS HR, 0.76 [95% CI, 0.50-1.16; P 5 .21])
BM, bone marrow; CR1, first complete remission; WBC, white blood cell.
*Mutations detected in $5% of tested patients are shown. (Figure 1D-F). Notably, among MRD-positive patients, level of
MRD (ie, ,0.1% vs 0.1%-0.99% vs $1%) did not affect CIR
(P 5 .88), RFS (P 5 .85), or OS (P 5 .91).
duration ,1 year, and 38 (48%) had a first remission duration $1 Impact of HSCT on outcomes
year. Thirteen patients (9%) had undergone prior HSCT. The
majority of patients (87%) achieved best response after 1 cycle of Sixty-two patients (44%) underwent allogeneic HSCT after first salvage
salvage therapy. therapy, with a median time of 1.4 months between achievement of
second remission and HSCT. HSCT after first salvage therapy was the
The median duration of follow-up of the entire cohort was 30.5 months strongest prognostic factor identified for CIR, RFS, and OS (P , .001
(range, 0.3-80.3 months). The 1- and 2-year CIR rates were 59% and for all). HSCT rate was higher in those who achieved CR vs CRi/MLFS
67%, respectively. Median RFS was 5.6 months, with 1- and 2-year (52% vs 28%, respectively; P 5 .008) and in those who were MRD
RFS rates of 34% and 23%. Median OS was 11.2 months, with 1- and negative vs MRD positive (52% vs 31%; P 5 .01).
2-year OS rates of 48% and 29%. Overall, 15 patients relapsed within 1.4 months after achievement
of second remission. The relapse rate in this period was significantly
Response rates higher in patients who achieved only CRi/MLFS and/or were MRD
Ninety-five patients (67%) achieved CR, 26 (18%) achieved CRi, positive compared with those who achieved CRMRD–. The relapse
and 20 (14%) achieved MLFS as best response to salvage therapy. rates within 1.4 months of second remission for patients who

22 DECEMBER 2020 x VOLUME 4, NUMBER 24 CR WITH MRD NEGATIVITY IN RELAPSED AML 6119
 A Median time D Median time
N to relapse 2-year relapse N to relapse 2-year relapse
100 CR 95 9.2 months 64% 100 MRD negative 86 10.6 months 61%
CRi/MLFS 46 3.8 months 70% MRD positive 55 4.7 months 76%
P=0.01 P=0.01
75 75
Relapse risk (%)

Relapse risk (%)

50 50

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25 25

0 0
0 12 24 36 48 60 72 84 0 12 24 36 48 60 72 84
Time (months) Time (months)

B N Median RFS 2-year RFS E N Median RFS 2-year RFS

100 CR 95 7.9 months 26% 100 MRD negative 86 7.3 months 26%
CRi/MLFS 46 2.6 months 13% MRD positive 55 4.6 months 15%
P=0.004 P=0.05
75 75
Relapse-free survival (%)

Relapse-free survival (%)

50 50

25 25

0 0
0 12 24 36 48 60 72 84 0 12 24 36 48 60 72 84
Time (months) Time (months)

C N Median OS 2-year OS F N Median OS 2-year OS

100 CR 95 11.2 months 32% 100 MRD negative 86 12.3 months 34%
CRi/MLFS 46 9.4 months 18% MRD positive 55 10.5 months 20%
P=0.15 P=0.21
75 75
Overall survival (%)

Overall survival (%)

50 50

25 25

0 0
0 12 24 36 48 60 72 84 0 12 24 36 48 60 72 84
Time (months) Time (months)

Figure 1. Outcomes of patients according to hematologic recovery and MRD status. CIR (A), RFS (B), and OS (C) for the entire cohort, stratified according to
hematologic response to salvage chemotherapy. CIR (D), RFS (E), and OS (F) for the entire cohort, stratified according to MRD response to salvage chemotherapy.

6120 SHORT et al 22 DECEMBER 2020 x VOLUME 4, NUMBER 24

achieved CRMRD–, CR with MRD positivity, CRi/MLFS with MRD
negativity, and CRi/MLFS with MRD positivity were 3%, 15%, 8%, A
100
and 29%, respectively. Overall, 2 (3%) of 61 patients with CRMRD–
relapsed in this period, compared with 13 (16%) of 80 patients with
CRi/MLFS and/or MRD positivity (P 5 .01). This increased rate of
very early relapse was a major driver of the inferior outcomes 75
observed in this latter group. N Median time to relapse 2-year relapse

Relapse risk (%)

CR MRD- / no HSCT 22 4.1 months 94%

In a landmark HSCT analysis, 22 patients who relapsed (n 5 15), died in Others / no HSCT 35 2.5 months 100%
CR MRD- / HSCT 37 Not reached 34%
remission (n 5 4), or were lost to follow-up (n 5 3) within 1.4 months of 50
Others / HSCT 25 Not reached 28%
second remission were excluded. Among the remaining 57 patients who
did not undergo HSCT in second remission, stratification of patients into
4 groups according to hematologic response (CR vs CRi/MLFS) and

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25
MRD response (positive vs negative) was associated with significant
differences in CIR (P 5 .004) and RFS (P 5 .008) but not OS (P 5 .8)
(supplemental Figure 1A-C). As expected, outcomes in patients who did
0
not undergo HSCT in second remission were very poor, regardless of 0 12 24 36 48 60 72 84
their response to salvage chemotherapy, with only 1 patient alive without Time (months)
relapse or death at 2 years.
Overall, 62 patients underwent HSCT in first remission. The B
conditioning regimen was myeloablative in 37 of these patients 100 N Median RFS 2-year RFS
CR MRD- / no HSCT 22 3.7 months 6%
(60%) and reduced-intensity in 25 patients (40%). Twelve patients Others / no HSCT 35 3.5 months 0%
(19%) received post-HSCT maintenance therapy (azacitidine, CR MRD- / HSCT 37 20.1 months 46%
n 5 6; sorafenib, n 5 3; crenolanib, n 5 2; SGI-110, n 5 1). 75
Others / HSCT 25 20.4 months 49%

Outcomes were significantly better for patients who underwent Relapse-free survival (%)
HSCT, regardless of their response to first salvage therapy
(Figure 2). Interestingly, among patients who underwent HSCT,
50
neither hematologic nor MRD response after salvage therapy was
associated with CIR (P 5 .94), RFS (P 5 .77), or OS (P 5 .54)
(supplemental Figure 2A-C). Fifty-nine of these patients also had
pre-HSCT MRD information available (defined as MRD assessment 25
within 6 weeks before HSCT), which was analyzed for impact on
clinical outcomes. Forty-two of the 59 patients with pre-HSCT MRD
information had at least one additional MRD assessment performed 0
before HSCT. Thirty patients who were MRD negative remained 0 12 24 36 48 60 72 84
MRD negative before HSCT, 1 patient converted from MRD Time (months)
negative to MRD positive, 7 patients converted from MRD positive
to MRD negative, and 4 patients who were MRD positive remained C
MRD positive before HSCT. Overall, 50 patients (85%) were 100 N Median OS 2-year OS
MRD negative and 9 patients (15%) were MRD positive before CR MRD- / no HSCT 22 8.2 months 25%
Others / no HSCT 35 6.9 months 8%
HSCT. Among MRD-positive patients, the median level of pre-HSCT CR MRD- / HSCT 37 20.1 months 45%
MRD was 0.5% (range, 0.04%-2%). MRD status before HSCT Others / HSCT 25 36.9 months 50%
75
was not associated with differential outcomes with respect to either
CIR (P 5 .70), RFS (P 5 .46), or OS (P 5 .48) (supplemental
Overall survival (%)

Figure 3A-C).
50
Multivariate analysis and integration of hematologic
recovery and MRD response
According to multivariate analysis, including established predictors 25
for outcomes in relapsed/refractory AML (modified from Breems
et al17) and using HSCT as a time-dependent variable, both CR and
MRD negativity were independently associated with lower CIR (HR 0
of 0.45 [95% CI, 0.28-0.73; P 5 .001] and HR of 0.50 [95% CI, 0 12 24 36 48 60 72 84
0.32-0.79; P 5 .003], respectively) and better RFS (HR of 0.46 Time (months)
[95% CI, 0.30-0.71; P , .001] and HR of 0.62 [95% CI, 0.41-0.93;
P 5 .02]) but not with OS (Table 2; supplemental Tables 4-6). Figure 2. Outcomes of patients according to hematologic recovery, MRD status,
and subsequent HSCT. CIR (A), RFS (B), and OS (C) stratified according to CRMRD–
In light of the favorable and independent prognostic impact of
vs lesser responses and HSCT vs no HSCT. Landmark analysis excluded patients who
achieving CR and of achieving MRD negativity, as well as to assess
relapsed or died within 1.4 months from the time of response to salvage chemotherapy.
whether CRMRD– might be the optimal response for patients with

22 DECEMBER 2020 x VOLUME 4, NUMBER 24 CR WITH MRD NEGATIVITY IN RELAPSED AML 6121
relapsed/refractory AML, these variables were combined for
analyses of relapse and survival outcomes. Integration of hemato- A
100
logic recovery and MRD information appeared to stratify patients
into 3 groups according to CIR and RFS, ranging from most
favorable outcomes to poorest outcomes: (1) CRMRD–; (2) CR with
MRD positivity or CRi/MLFS with MRD negativity; and (3) CRi/MLFS 75
with MRD positivity (Figure 3A-B). The 1-year CIR rates for these

Relapse risk (%)

groups were 47%, 67%, and 76%, respectively (P 5 .001), and
the median RFS were 10.1 months, 5.1 months, and 2.4 months 50
(P 5 .004). However, OS was not significantly different between
groups when stratified according to hematologic recovery and
MRD status (P 5 .29) (Figure 3C). N Median time to relapse 2-year relapse

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25 CR MRD- 61 13.1 months 58%

Patients who achieved CRMRD– as best response (n 5 61 [43% of CR MRD+ 34 5.5 months 73%
P=0.001
CRi/MLFS MRD- 25 5.1 months 65%
the entire cohort]) had better outcomes than those who achieved CRi/MLFS MRD+ 21 2.4 months not evaluable
CR/MLFS and/or MRD positivity. Patients who achieved CRMRD–
0
had significantly lower CIR (2-year CIR rate, 58% vs 73% [HR,
0 12 24 36 48 60 72 84
0.52; 95% CI, 0.33-0.82; P 5 .004]) (Figure 4A) and better RFS
Time (months)
(2-year RFS rate, 30% vs 15% [HR, 0.58; 95% CI, 0.39-0.87;
P 5 .008]) (Figure 4B). A trend for better OS was also observed
B
in patients who achieved CRMRD– (2-year OS rate, 37% vs 21%
100
[HR, 0.70; 95% CI, 0.46-1.07; P 5 .10]) (Figure 4C). N Median RFS 2-year RFS
CR MRD- 61 10.1 months 30%
The impact of achieving CRMRD– vs lesser responses was similar in CR MRD+ 34 5.5 months 17%
P=0.004
both younger and older populations. Achievement of CRMRD– was 75
CRi/MLFS MRD- 25 4.6 months 14%

associated with better RFS in patients aged ,60 years (HR, 0.60; Relapse-free survival (%)
CRi/MLFS MRD+ 21 2.4 months not evaluable

95% CI, 0.35-1.05; P 5 .07) and in patients aged $60 years (HR,
0.57; 95% CI, 0.33-1.01; P 5 .05). Patients with diploid
50
cytogenetics who achieved CRMRD– had a trend toward better
RFS compared with those with lesser responses (HR, 0.66; 95%
CI, 0.35-1.25; P 5 .20); this benefit of CRMRD– was also observed
in patients with non-diploid cytogenetics (HR, 0.60; 95% CI, 0.36- 25
0.99; P 5 .047).

Discussion
0
CR with full hematologic recovery and achievement of MRD 0 12 24 36 48 60 72 84
negativity have both been shown in several studies to be associated Time (months)

Table 2. Multivariate analysis for CIR, RFS, and OS C

Characteristic HR (95% CI) P 100
N Median OS 2-year OS
CIR CR MRD- 61 12.4 months 37%
CR MRD+ 34 11.2 months 23%
MRD status (negative vs positive) 0.50 (0.32-0.79) .003 P=0.29
CRi/MLFS MRD- 25 16.9 months 22%
75
Response (CR vs CRi/MLFS) 0.45 (0.28-0.73) .001 CRi/MLFS MRD+ 21 9.4 months not evaluable
Overall survival (%)

Log of platelets 0.74 (0.59-0.94) .01

HSCT after salvage therapy (time-dependent) 0.20 (0.11-0.35) ,.001

50
RFS

MRD status (negative vs positive) 0.62 (0.41-0.93) .02

Response (CR vs CRi/MLFS) 0.46 (0.30-0.71) ,.001
25
Log of platelets 0.77 (0.63-0.96) .02
HSCT after salvage therapy (time-dependent) 0.25 (0.15-0.41) .02

OS 0
Cytogenetics (diploid vs others) 0.58 (0.38-0.88) .01 0 12 24 36 48 60 72 84

HSCT after salvage therapy (time-dependent) 0.28 (0.18-0.46) ,.001 Time (months)

Variables included in multivariate analysis were: age, white blood cell count, platelet Figure 3. Outcomes of patients according to integrated hematologic and
count, hemoglobin, bone marrow blast percentage, cytogenetics (diploid vs others),
response to first induction (relapsed with first remission duration $1 year vs relapsed with MRD response. CIR (A), RFS (B), and OS (C) for the entire cohort, stratified
first remission duration ,1 year or refractory), prior HSCT, HSCT after salvage therapy (as according to hematologic and MRD responses to salvage chemotherapy.
time-dependent variable), hematologic response (CR vs CRi/MLFS), and MRD response
(negative vs positive).

6122 SHORT et al 22 DECEMBER 2020 x VOLUME 4, NUMBER 24

 with superior outcomes in patients with AML undergoing frontline
A therapy.4-15 In contrast, established prognostic factors in the
Median time
relapsed/refractory setting have historically been limited to pre-
100 N to relapse 2-year relapse
treatment clinical variables.17 In this study of patients with relapsed/
CR MRD- 61 13.1 months 58%
P=0.004 refractory AML treated with first salvage chemotherapy, we showed
Others 80 4.7 months 73%
that achievement of CR and MRD negativity by MFC are both
75 independently associated with lower rates of relapse and superior
RFS, even when accounting for subsequent HSCT. When
Relapse risk (%)

hematologic recovery and MRD status were integrated, the best

50 outcomes were observed in patients who achieved CRMRD– (43%
of patients in the cohort), and the superior outcomes in these
patients were driven, at least in part, by their ability to be bridged to

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25 allogeneic HSCT. Together, these data support the European
LeukemiaNet consensus guidelines defining CRMRD– as the optimal
response in AML16 and provide evidence that this response
0 definition is also applicable to patients with relapsed/refractory
0 12 24 36 48 60 72 84 disease.
Time (months) In nearly all fit patients with relapsed/refractory AML (with the
possible exception of select patients with core binding factor
B AML25), the goal of salvage therapy is to induce a response and
100 N Median RFS 2-year RFS bridge to potentially curative allogeneic HSCT. Because coordina-
CR MRD- 61 10.1 months 30% tion of HSCT may take $6 weeks, transient responses may not
P=0.008
Others 80 4.6 months 15% provide adequate disease control to proceed with HSCT and thus
75 may require additional lines of treatment before HSCT can be
Relapse-free survival (%)

performed. We found that the rate of very early relapse (ie, within
1.4 months, which was the median time to HSCT in our study) was
50 lower in patients who achieved CRMRD– vs those who achieved
lesser responses (relapse rate within 1.4 months, 3% and 16%,
respectively), which increased the ability of patients with CRMRD– to
undergo HSCT after first salvage. In contrast, the suboptimal
25
disease control associated with achieving only CRi/MLFS or MRD
positivity contributed to the poorer outcomes of these patients,
largely because fewer patients with these responses were able to
0 undergo potentially curative HSCT. Not surprisingly, the outcomes
0 12 24 36 48 60 72 84
of patients who did not undergo subsequent HSCT were poor,
Time (months) regardless of initial response to salvage chemotherapy. Although
risk of relapse was lower, and RFS was superior for patients who
C achieved CR and/or MRD negativity, outcomes were still universally
100 N Median OS 2-year OS poor in all groups who did not undergo HSCT, with only 1 patient
CR MRD- 61 12.4 months 37% being alive without relapse 2 years after first salvage.
P=0.10
Others 80 10.6 months 21%
Previous reports, including a meta-analysis of 19 studies, have
75
largely shown that achievement of MRD negativity before HSCT is
Overall survival (%)

associated with superior post-HSCT outcomes.10-13,26 In contrast,

we found that MRD response after salvage chemotherapy or
50 immediately before HSCT did not affect relapse rates or survival
after HSCT. Our finding is consistent with another retrospec-
tive report that showed no difference in post-HSCT outcomes
25 according to pre-HSCT MRD status (measured by MFC) in patients
with relapsed or refractory AML.27 There are also emerging data
that a myeloablative conditioning regimen may overcome the poor
0 prognostic impact of pre-HSCT MRD when HSCT is performed in
0 12 24 36 48 60 72 84 first remission, although similar analyses in patients in second
Time (months) remission or beyond are lacking.28,29 One limitation of our study is
that the number of patients with pre-HSCT MRD information
Figure 4. Outcomes of patients achieving CRMRD– vs lesser responses. CIR available was relatively small (n 5 59), with only 9 patients who were
(A), RFS (B), and OS (C) for the entire cohort, stratified according to CRMRD– vs MRD positive before HSCT; it was therefore not possible to perform
lesser responses. meaningful subgroup analyses evaluating the interaction between
conditioning regimen and pre-HSCT MRD status. One recent
study has suggested that myeloablative and reduced-intensity

22 DECEMBER 2020 x VOLUME 4, NUMBER 24 CR WITH MRD NEGATIVITY IN RELAPSED AML 6123
conditioning regimens result in similar survival outcomes in patients Our findings that hematologic recovery and MRD status do not
who undergo transplant in second remission.30 Further analyses significantly affect post-HSCT outcomes also inform the optimal
integrating both conditioning intensity and MRD status in the timing of HSCT in the salvage setting. In contrast with the frontline
salvage setting are therefore warranted. setting, where outcomes after HSCT are significantly better in
When comparing our results vs those of other reported studies on patients who achieve MRD negativity, we found no difference in post-
the impact of pre-HSCT MRD, it is important to note that most of HSCT outcomes according to response to salvage chemotherapy or
these other studies were limited to patients who underwent pre-HSCT MRD. Our data therefore suggest that, whenever possible,
transplant in first remission or combined patients who underwent immediate HSCT should be considered for any patient with relapsed/
transplant in first or later remissions in their analysis. However, AML refractory AML who achieves a marrow remission, regardless of
disease biology is significantly different in patients who have not hematologic recovery or MRD response. In light of the high rates of
responded to or who relapsed after frontline therapy and is early relapse in patients who achieve only CRi/MLFS and/or MRD
characterized by increased clonal complexity and chemoresist- positivity, our findings argue against a practice of attempting to

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ance.31 We therefore hypothesize that patients who achieve “MRD administer additional cycles of chemotherapy in an effort to deepen
negativity” after frontline therapy and those who seemingly achieve a patient’s response before undergoing HSCT in the salvage setting;
this may sometimes be necessary, however, when HSCT is not yet
the same response after salvage chemotherapy likely possess very
different quantities of residual disease that are present below the available.
level of detection of the MRD assay (in our study, sensitivity of at In conclusion, among patients with relapsed/refractory AML receiving
least 0.1%). This could similarly explain why patients in our study first salvage chemotherapy, both CR and MRD negativity were
who were able to proceed to HSCT had similar post-HSCT independently associated with a lower risk of relapse and longer RFS.
outcomes, regardless of response to salvage chemotherapy. It is Patients who achieved CRMRD– had the best outcomes, which were
very possible that in the relapsed/refractory setting in which the driven in part by an increased ability to undergo subsequent HSCT.
disease is generally more chemoresistant, the difference in total Given the superior outcomes in patients who achieve CRMRD–, this
quantity of residual disease between patients who are “MRD response end point should be considered in clinical trials evaluating
negative” and “MRD positive” is less pronounced than in the frontline novel agents and combinations in relapsed/refractory AML.
setting, and these differences therefore may be more easily negated
by HSCT. Additional studies using ultrasensitive MRD assays would Acknowledgments
be needed to better characterize and quantify the true level of residual
This study was supported by an MD Anderson Cancer Center
disease that persists after chemotherapy, how these differ between
Support Grant (CA016672) and SPORE. N.J.S. is supported by the
frontline and relapsed/refractory patients, and how these very small
K12 Paul Calabresi Clinical Oncology Scholar Award and the
amounts of residual disease affect outcomes after HSCT. Such an
American Society of Hematology Junior Faculty Scholar Award in
approach will be particularly important in the frontline setting in which
Clinical Research.
deep MRD-negative responses identified by using highly sensitive
assays may help to the inform decision for HSCT in first remission. Authorship
There are several important implications of our findings. First, the Contribution: N.J.S., H.R., and F.R. designed the study, collected and
strong and independent impact of both CR and MRD negativity on analyzed the data, and wrote the manuscript; H.H. and J.N. per-
risk of relapse and RFS support the use of CRMRD– as a valuable end formed statistical analyses; J.L.J. and S.A.W. performed MRD anal-
point for clinical trials in patients with relapsed/refractory AML, which yses; N.D., J.C., T.M.K., C.D.D., E.J., U.P., B.O., M.K., M.Y., G.C.I., and
may allow for more rapid clinical evaluation and approval of novel H.K. treated patients; and all authors reviewed and approved the
agents. Although the impact of achieving CRMRD– was not statistically manuscript.
associated with OS (2-year OS rate, 37% vs 21%; P 5 .10), there
was a strong trend toward better OS in patients who achieved Conflict-of-interest disclosure: The authors declare no compet-
CRMRD–, with these patients having nearly twice the 2-year OS rate as ing financial interests.
those with lesser responses. The lack of a significant difference may
ORCID profiles: H.R., 0000-0002-5724-4183; N.D., 0000-
be in part due to the increasing availability of effective salvage
0001-7103-373X; C.D.D., 0000-0001-9003-0390; U.P., 0000-
regimens for these patients, including the development of novel FMS-
0002-7592-2224; M.K., 0000-0002-9347-2212; H.K., 0000-
like tyrosine kinase 3 inhibitors (eg, gilteritinib), IDH1 and IDH2
0002-1908-3307.
inhibitors (eg, ivosidenib and enasidenib), and venetoclax-based
regimens, which became available in clinical trials and commercially Correspondence: Nicholas J. Short, Department of Leukemia,
over the study period.32 However, it remains possible that with a larger Unit 428, The University of Texas MD Anderson Cancer Center,
cohort of patients, an OS benefit might have been observed, which 1515 Holcombe Blvd, Houston, TX 77030; e-mail: nshort@
would further support the importance of CRMRD– in this context. mdanderson.org.

References

1. Short NJ, Rytting ME, Cortes JE. Acute myeloid leukaemia. Lancet. 2018;392(10147):593-606.
2. Papaemmanuil E, Gerstung M, Bullinger L, et al. Genomic classification and prognosis in acute myeloid leukemia. N Engl J Med. 2016;374(23):
2209-2221.

6124 SHORT et al 22 DECEMBER 2020 x VOLUME 4, NUMBER 24

3. Short NJ, Ravandi F. How close are we to incorporating measurable residual disease into clinical practice for acute myeloid leukemia? Haematologica.
2019;104(8):1532-1541.
4. Walter RB, Kantarjian HM, Huang X, et al. Effect of complete remission and responses less than complete remission on survival in acute myeloid
leukemia: a combined Eastern Cooperative Oncology Group, Southwest Oncology Group, and M.D. Anderson Cancer Center Study. J Clin Oncol.
2010;28(10):1766-1771.
5. Chen X, Xie H, Wood BL, et al. Relation of clinical response and minimal residual disease and their prognostic impact on outcome in acute myeloid
leukemia. J Clin Oncol. 2015;33(11):1258-1264.
6. Ravandi F, Jorgensen J, Borthakur G, et al. Persistence of minimal residual disease assessed by multiparameter flow cytometry is highly prognostic in
younger patients with acute myeloid leukemia. Cancer. 2017;123(3):426-435.
7. Terwijn M, van Putten WL, Kelder A, et al. High prognostic impact of flow cytometric minimal residual disease detection in acute myeloid leukemia: data
from the HOVON/SAKK AML 42A study. J Clin Oncol. 2013;31(31):3889-3897.
8. Freeman SD, Virgo P, Couzens S, et al. Prognostic relevance of treatment response measured by flow cytometric residual disease detection in older

Downloaded from http://ashpublications.org/bloodadvances/article-pdf/4/24/6117/1796127/advancesadv2020002811.pdf by guest on 24 January 2021

patients with acute myeloid leukemia. J Clin Oncol. 2013;31(32):4123-4131.
9. Freeman SD, Hills RK, Virgo P, et al. Measurable residual disease at induction redefines partial response in acute myeloid leukemia and stratifies
outcomes in patients at standard risk without NPM1 mutations. J Clin Oncol. 2018;36(15):1486-1497.
10. Walter RB, Gooley TA, Wood BL, et al. Impact of pretransplantation minimal residual disease, as detected by multiparametric flow cytometry, on outcome
of myeloablative hematopoietic cell transplantation for acute myeloid leukemia. J Clin Oncol. 2011;29(9):1190-1197.
11. Walter RB, Buckley SA, Pagel JM, et al. Significance of minimal residual disease before myeloablative allogeneic hematopoietic cell transplantation for
AML in first and second complete remission. Blood. 2013;122(10):1813-1821.
12. Araki D, Wood BL, Othus M, et al. Allogeneic hematopoietic cell transplantation for acute myeloid leukemia: time to move toward a minimal residual
disease-based definition of complete remission? J Clin Oncol. 2016;34(4):329-336.
13. Zhou Y, Othus M, Araki D, et al. Pre- and post-transplant quantification of measurable (“minimal”) residual disease via multiparameter flow cytometry in
adult acute myeloid leukemia. Leukemia. 2016;30(7):1456-1464.
14. Feller N, van der Pol MA, van Stijn A, et al. MRD parameters using immunophenotypic detection methods are highly reliable in predicting survival in acute
myeloid leukaemia. Leukemia. 2004;18(8):1380-1390.
15. Short NJ, Zhou S, Fu C, et al. Association of measurable residual disease with survival outcomes in patients with acute myeloid leukemia: a systematic
review and meta-analysis [published online ahead of print 8 October 2020]. JAMA Oncol. doi:10.1001/jamaoncol.2020.4600
16. Döhner H, Estey E, Grimwade D, et al. Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel.
Blood. 2017;129(4):424-447.
17. Breems DA, Van Putten WL, Huijgens PC, et al. Prognostic index for adult patients with acute myeloid leukemia in first relapse. J Clin Oncol. 2005;23(9):
1969-1978.
18. Lanza B, Martinelli G, Yee KWL, et al. Minimal residual disease (MRD) assessment by multiparametric flow cytometry is prognostic for progression-free
survival in Phase 1/1b relapsed/refractory acute myeloid leukemia (AML) patients treated with idasanutlin MDM2 antagonist. Blood. 2016;128(22):2843.
19. Reis B, Jukofsky L, Chen G, et al. Acute myeloid leukemia patients’ clinical response to idasanutlin (RG7388) is associated with pre-treatment MDM2
protein expression in leukemic blasts. Haematologica. 2016;101(5):e185-e188.
20. DiNardo CD, Stein EM, de Botton S, et al. Durable remissions with ivosidenib in IDH1-mutated relapsed or refractory AML. N Engl J Med. 2018;378(25):
2386-2398.
21. Levis MJ, Perl AE, Altman JK, et al. Evaluation of the impact of minimal residual disease, FLT3 allelic ratio, and FLT3 mutation status on overall survival in
FLT3 mutation-positive patients with relapsed/refractory (R/R) acute myeloid leukemia (AML) in the Chrysalis Phase 1/2 study [abstract]. Blood. 2017;
130(suppl 1):Abstract 2705.
22. Yin JA, O’Brien MA, Hills RK, Daly SB, Wheatley K, Burnett AK. Minimal residual disease monitoring by quantitative RT-PCR in core binding factor AML
allows risk stratification and predicts relapse: results of the United Kingdom MRC AML-15 trial. Blood. 2012;120(14):2826-2835.
23. Ouyang J, Goswami M, Tang G, et al. The clinical significance of negative flow cytometry immunophenotypic results in a morphologically scored positive
bone marrow in patients following treatment for acute myeloid leukemia. Am J Hematol. 2015;90(6):504-510.
24. Jaso JM, Wang SA, Jorgensen JL, Lin P. Multi-color flow cytometric immunophenotyping for detection of minimal residual disease in AML: past, present
and future. Bone Marrow Transplant. 2014;49(9):1129-1138.
25. Kurosawa S, Miyawaki S, Yamaguchi T, et al. Prognosis of patients with core binding factor acute myeloid leukemia after first relapse. Haematologica.
2013;98(10):1525-1531.
26. Buckley SA, Wood BL, Othus M, et al. Minimal residual disease prior to allogeneic hematopoietic cell transplantation in acute myeloid leukemia:
a meta-analysis. Haematologica. 2017;102(5):865-873.
27. Tian H, Chen GH, Xu Y, et al. Impact of pre-transplant disease burden on the outcome of allogeneic hematopoietic stem cell transplant in refractory and
relapsed acute myeloid leukemia: a single-center study. Leuk Lymphoma. 2015;56(5):1353-1361.
28. Gilleece MH, Labopin M, Yakoub-Agha I, et al. Measurable residual disease, conditioning regimen intensity, and age predict outcome of allogeneic
hematopoietic cell transplantation for acute myeloid leukemia in first remission: a registry analysis of 2292 patients by the Acute Leukemia Working Party
European Society of Blood and Marrow Transplantation. Am J Hematol. 2018;93(9):1142-1152.
29. Hourigan CS, Dillon LW, Gui G, et al. Impact of conditioning intensity of allogeneic transplantation for acute myeloid leukemia with genomic evidence of
residual disease. J Clin Oncol. 2020;38(12):1273-1283.

22 DECEMBER 2020 x VOLUME 4, NUMBER 24 CR WITH MRD NEGATIVITY IN RELAPSED AML 6125
30. Gilleece MH, Labopin M, Savani BN, et al. Allogeneic haemopoietic transplantation for acute myeloid leukaemia in second complete remission: a registry
report by the Acute Leukaemia Working Party of the EBMT. Leukemia. 2020;34(1):87-99.
31. Ding L, Ley TJ, Larson DE, et al. Clonal evolution in relapsed acute myeloid leukaemia revealed by whole-genome sequencing. Nature. 2012;481(7382):
506-510.
32. Short NJ, Konopleva M, Kadia TM, et al. Advances in the treatment of acute myeloid leukemia: new drugs and new challenges. Cancer Discov. 2020;
10(4):506-525.

Downloaded from http://ashpublications.org/bloodadvances/article-pdf/4/24/6117/1796127/advancesadv2020002811.pdf by guest on 24 January 2021

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