Icon of Test TubeHow do I test for
MRD?

According to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), testing for measurable residual disease (MRD) first requires a bone marrow sample.1 The highest quality sample comes from the first or an early pull, to avoid hemodilution.2 A small (eg, 2–3 mL) sample aspirated after the needle is introduced into the bone marrow is preferred.1,2 The second pull has shown an approximately 50% reduction in leukemic cells.2 When a bone marrow sample cannot be acquired, peripheral blood may be used as an alternative sample when high sensitivity methods for quantification are used; however, note that the use of bone marrow is preferred.3

Watch Aaron Logan discuss the
importance of the first bone
marrow aspirate pull

Video Thumbnail: Professor Aaron Logan Discusses Importance of First Bone Marrow Aspirate Pull Video Thumbnail: Professor Aaron Logan Discusses Importance of First Bone Marrow Aspirate Pull
Aaron Logan, MD, PhD

Associate Professor of Clinical Medicine
The University of California, San Francisco

MRD can be quantified by various methods, with sensitivity thresholds ranging from < 1 × 10-4 (< 0.01%) to < 1 x 10-6 ( < 0.0001%).
Consider consulting with a pathologist prior to testing for considerations that may yield the best results.1

There are 3 common techniques used to quantify MRD:1

Icon of Flow Cytometry Icon of Q-PCR Icon of NGS
Type of test Flow cytometry Quantitative polymerase chain reaction (Q-PCR) Next-generation sequencing (NGS)
Target Leukemia-associated
immunophenotypes4
Immunoglobulin/T-cell receptor
gene rearrangements or gene
fusions (eg, BCR-ABL1)5
Immunoglobulin/T-cell receptor
gene rearrangements6
Typical
sensitivity*
1 cancer cell in 10,000
normal cells (0.01%)6
1 cancer cell in 100,000
normal cells (0.001%)6
1 cancer cell in 1,000,000
normal cells (0.0001%)6
Turnaround
time
~ 1 day4,5 ~ 1–2 weeks (eg, BCR-ABL1)7

3–4 weeks for diagnostic
sample, ~ 1 week for follow-up
analyses (ASO-PCR)8
~ 1 week4
Sample
requirements
Fresh sample6

Baseline sample preferred but not required6,†
Requires baseline sample, or prior
sample obtained at diagnosis with
detectable disease6
Requires baseline sample, or prior
sample obtained at diagnosis with
detectable disease6
Additional
considerations
≥ 6-color assays are the most commonly used vs other color assays to detect abnormal MRD immunophenotypes1

Adequate sensitivity for MRD
quantification requires special
calibration and assessment of a large number of cells and
may not be available from
some labs8

Requires significant
expertise for analysis6

Limited standardization across testing facilities6
BCR-ABL1 PCR is applicable
only in Ph(+) patients9

ASO-PCR utilizes
patient-specific ASO primers (limited availability in the US)9

Limited standardization across testing facilities, depending
on assay6
FDA-cleared NGS assay available6

Limited standardization across testing facilities using other NGS approaches6
Icon of Flow Cytometry
Type of test Flow cytometry
Target Leukemia-associated
immunophenotypes4
Typical
sensitivity*
1 cancer cell in 10,000
normal cells (0.01%)6
Turnaround
time
~ 1 day4,5
Sample
requirements
Fresh sample6

Baseline sample preferred but not required6,†
Additional
considerations
≥ 6-color assays are the most commonly used vs other color assays to detect abnormal MRD immunophenotypes1

Adequate sensitivity for MRD
quantification requires special
calibration and assessment of a large number of cells and
may not be available from
some labs8

Requires significant
expertise for analysis6

Limited standardization across testing facilities6
Icon of Q-PCR
Type of test Quantitative polymerase
chain reaction (Q-PCR)
Target Immunoglobulin/T-cell receptor
gene rearrangements or gene
fusions (eg, BCR-ABL1)5
Typical
sensitivity*
1 cancer cell in 100,000
normal cells (0.001%)6
Turnaround
time
~ 1–2 weeks (eg, BCR-ABL1)7

3–4 weeks for diagnostic
sample, ~ 1 week for follow-up
analyses (ASO-PCR)8
Sample
requirements
Requires baseline sample, or prior
sample obtained at diagnosis with
detectable disease6
Additional
considerations
BCR-ABL1 PCR is applicable
only in Ph(+) patients9

ASO-PCR utilizes
patient-specific ASO primers (limited availability in the US)9

Limited standardization across testing facilities, depending
on assay6
Icon of NGS
Type of test Next-generation
sequencing (NGS)
Target Immunoglobulin/T-cell receptor
gene rearrangements6
Typical
sensitivity*
1 cancer cell in 1,000,000
normal cells (0.0001%)6
Turnaround
time
~ 1 week4
Sample
requirements
Requires baseline sample, or prior
sample obtained at diagnosis with
detectable disease6
Additional
considerations
FDA-cleared NGS assay available6

Limited standardization across testing facilities using other NGS approaches6

Icon of ClockGuideline recommendations for when to test for MRD

Icon of Clock

Guideline recommendations for when to test for MRD

NCCN Guidelines® state that measurable residual disease (MRD) is an essential component of patient evaluation over the course of sequential therapy in pediatric and adult patients with ALL.1,10 The guidelines recommend MRD characterization of leukemic clones at diagnosis, MRD testing upon completion of initial induction therapy, and subsequent MRD testing at various time points throughout a patient’s treatment journey.1,10

MRD testing timeline1,10,‡

Image of MRD Testing Timeline for both Adult and Pediatric ALL Image of MRD Testing Timeline for both Adult and Pediatric ALL

Diagnosis

Baseline sample may be
required or helpful to
characterize leukemic clones
to perform subsequent
MRD analysis§

End of induction**

CR does not exclude the
possible presence of
residual leukemic cells in
the bone marrow

End of consolidation††
Surveillance

Adults: Every 3–6 months
as clinically indicated for at
least 5 years
Pediatric: for suspected
relapse‡‡

MRD status plays an important
role in a patient’s treatment
journey, and an MRD(+) test
result may prompt additional
intervention or a change
in treatment1,10

Aaron Logan discusses
the MRD testing methods:

Video Thumbnail: Professor Aaron Logan Discusses the MRD Testing Methods Video Thumbnail: Professor Aaron Logan Discusses the MRD Testing Methods
Aaron Logan, MD, PhD

Associate Professor of Clinical Medicine
The University of California, San Francisco

James McCloskey shares
his
perspective on
when to test for MRD:

Video Thumbnail: Interim Chief James McCloskey shares perspective on when to test for MRD Video Thumbnail: Interim Chief James McCloskey shares perspective on when to test for MRD
James McCloskey, MD

Interim Chief, Division of Leukemia
The John Theurer Cancer Center

Icon of Location

Where can I test
for MRD?

Icon of LocationWhere can I test
for MRD?

The measurable residual disease (MRD) test can be performed in-house at some institutions, or the sample can be sent to an outside laboratory if necessary.11 You can speak with your pathologist first, as they may have some input or experience with how and where to test.

Icon of ReportsMRD pathology reports: helpful perspectives

Icon of Reports

MRD pathology reports: helpful perspectives

Useful information to include in an MRD pathology report based on the clinical experience of the opinion leaders brought together by Amgen Oncology

The following information could be useful to include in a measurable residual disease (MRD) pathology report:

Interpretation of MRD test results

You may consider the following based on the clinical experience of the opinion leaders brought together by Amgen Oncology:

MRD sample journey

The measurable residual disease (MRD) testing journey involves several steps that require multidisciplinary communication among the ordering hematologist/oncologist, the pathologist, and the testing facility—from ordering an MRD test to processing and handling samples, reporting and interpreting test results, and determining the next steps in the treatment journey.12,17

Collaborating with your
multidisciplinary team
ensures optimal results
in MRD assessment12,17

Icon of EyeMRD resources for you and your practice

Icon of Eye

MRD resources for
you and your
practice

Image Thumbnail: Downloadable MRD at a Glance PDF Image Thumbnail: Downloadable MRD at a Glance PDF

Download MRD
at a glance

A resource containing practical
information on implementing MRD
testing in your practice

Image Thumbnail: Downloadable MRD Testing Facilities List Image Thumbnail: Downloadable MRD Testing Facilities List

Download the MRD
testing facilities list

A list of facilities that test for MRD, if
you are looking to test at an outside
center

Image Thumbnail: Downloadable Sample Pathology Report Presentation Image Thumbnail: Downloadable Sample Pathology Report Presentation

Download the sample
pathology report
presentation

A sample pathology report presentation that highlights considerations and best practices for MRD pathology report template creation, reporting, and interpretation of results

Image Thumbnail: Downloadable MRD Methodologies Presentsation Image Thumbnail: Downloadable MRD Methodologies Presentsation

Download the MRD
methodologies
presentation

From ordering an MRD test to interpreting the results, this resource illustrates MRD considerations throughout the testing journey

*Assays with < 0.01% sensitivity cannot be used to quantify MRD accurately.5

For different-from-normal (DfN) method only.6

AYA patients can be included in either pediatric or adult patient populations.1,10

§Dependent on MRD testing technique used.1,10

**Additional time points should be guided by the regimen used. Serial monitoring frequency may be increased in patients with molecular relapse or persistent low-level disease burden.1,10

††Additional time points should be guided by the regimen used.10

‡‡MRD testing may be included with a bone marrow aspirate.10

ALL, acute lymphoblastic leukemia; ASO, allele-specific oligonucleotides; AYA, adolescent and young adult; BCR-ABL1, breakpoint cluster region protein-abelson murine leukemia viral oncogene homolog 1; CD, cluster of differentiation; CR, complete remission; MRD, measurable residual disease; NCCN, National Comprehensive Cancer Network; NGS, next-generation sequencing; PCR, polymerase chain reaction; Ph(+), Philadelphia chromosome–positive; Q-PCR, quantitative PCR.

References: 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Acute Lymphoblastic Leukemia V.2.2021. © National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed November 30, 2021. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 2. Helgestad J, Rosthøj S, Johansen P, et al. Bone marrow aspiration technique may have an impact on therapy stratification in children with acute lymphoblastic leukaemia. Pediatr Blood Cancer. 2011;57:224-226. 3. Brüggemann M, Kotrova M. Minimal residual disease in adult ALL: technical aspects and implications for correct clinical interpretation. Blood Adv. 2017;1:2456-2466. 4. Kruse A, Abdel-Azim N, Na Kim H, et al. Minimal residual disease detection in acute lymphoblastic leukemia. Int J Mol Sci. 2020;21:1054. 5. Correia RP, Bento LC, de Sousa FA, et al. How I investigate minimal residual disease in acute lymphoblastic leukemia. Int J Lab Hematol. 2021;43:354-363. 6. Dalle IA, Jabbour E, Short NJ. Evaluation and management of measurable residual disease in acute lymphoblastic leukemia. Ther Adv Hematol. 2020;11:2040620720910023. 7. Paietta E. Immunobiology of acute leukemia. In: Wiernik PH, et al, eds. Neoplastic Diseases of the Blood. 6th ed. Springer; 2018:237-279. 8. van Dongen JJM, van der Velden VHJ, Brüggemann M, et al. Minimal residual disease diagnostics in acute lymphoblastic leukemia: need for sensitive, fast, and standardized technologies. Blood. 2015;125:3996-4009. 9. Akabane H, Aaron AC. Clinical significance and management of MRD in adults with acute lymphoblastic leukemia. Clin Adv Hematol Oncol. 2020;18:413-422. 10. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Pediatric Acute Lymphoblastic Leukemia V.1.2022. © National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed November 30, 2021. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 11. Ayala R, Onecha E. Next generation sequencing as the new gold standard for minimal residual disease detection in B-ALL. J Lab Precis Med. 2018;11:105. 12. Arber DA, Borowitz MJ, Cessna M, et al. Initial diagnostic workup of acute leukemia: guideline from the College of American Pathologists and the American Society of Hematology. Arch Pathol Lab Med. 2017;141:1342-1393. 13. Brüggemann M, Raff T, Kneba M. Has MRD monitoring superseded other prognostic factors in adult ALL? Blood. 2012;120:4470-4481. 14. Della Starza I, Chiaretti S, De Propris MS, et al. Minimal residual disease in acute lymphoblastic leukemia: technical and clinical advances. Front Oncol. 2019;9:726. 15. clonoSEQ®. https://adaptivebiotech.showpad.com/share/vENsMo9HgtZXfBdE0nd5x. Accessed November 30, 2021. 16. Brüggemann M, Gökbuget N, Kneba M. Acute lymphoblastic leukemia: monitoring minimal residual disease as a therapeutic principle. Semin Oncol. 2012;39:47-57. 17. Short NJ, Jabbour E, Albitar M, et al. Recommendations for the assessment and management of measurable residual disease in adults with acute lymphoblastic leukemia: a consensus of North American experts. Am J Hematol. 2019;94:257-265.

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