Standardization of molecular monitoring of CML: results and recommendations from the European treatment and outcome study

Helen E White^{1

2}, Matthew Salmon^{1

2}, Francesco Albano³, Christina Søs Auður Andersen⁴, Stefan Balabanov⁵, Gueorgui Balatzenko⁶, Gisela Barbany⁷, Jean-Michel Cayuela⁸, Nuno Cerveira⁹, Pascale Cochaux¹⁰, Dolors Colomer¹¹, Daniel Coriu^{12

13}, Joana Diamond¹⁴, Christian Dietz¹⁵, Stéphanie Dulucq¹⁶, Marie Engvall¹⁷, Georg N Franke¹⁸, Egle Gineikiene-Valentine¹⁹, Michal Gniot²⁰, María Teresa Gómez-Casares²¹, Enrico Gottardi²², Chloe Hayden²³, Sandrine Hayette²⁴, Andreas Hedblom²⁵, Anca Ilea^{26

27}, Barbara Izzo²⁸, Antonio Jiménez-Velasco²⁹, Tomas Jurcek^{30

31}, Veli Kairisto³², Stephen E Langabeer³³, Thomas Lion³⁴, Nora Meggyesi³⁵, Semir Mešanović³⁶, Luboslav Mihok³⁷, Gerlinde Mitterbauer-Hohendanner³⁸, Sylvia Moeckel³⁹, Nicole Naumann⁴⁰, Olivier Nibourel⁴¹, Elisabeth Oppliger Leibundgut^{42

43}, Panayiotis Panayiotidis⁴⁴, Helena Podgornik^{45

46}, Christiane Pott⁴⁷, Inmaculada Rapado^{48

49

50}, Susan J Rose⁵¹, Vivien Schäfer⁵², Tasoula Touloumenidou⁵³, Christopher Veigaard⁵⁴, Bianca Venniker-Punt⁵⁵, Claudia Venturi⁵⁶, Paolo Vigneri⁵⁷, Ingvild Vorkinn⁵⁸, Elizabeth Wilkinson⁵⁹, Renata Zadro⁶⁰, Magdalena Zawada⁶¹, Hana Zizkova⁶², Martin C Müller¹⁵, Susanne Saussele⁴⁰, Thomas Ernst⁵², Katerina Machova Polakova⁶², Andreas Hochhaus⁵², Nicholas C P Cross^{63

64}

Affiliations

¹ Faculty of Medicine, University of Southampton, Southampton, UK.
² Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury, UK.
³ Department of Emergency and Organ Transplantation (D.E.T.O.)-Hematology and Stem Cell Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy.
⁴ Department of Pathology, Zealand University Hospital, Roskilde, Denmark.
⁵ Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
⁶ Laboratory of Medical Genetics National Specialized Hospital for Active Treatment of Hematological Diseases, Sofia, Bulgaria.
⁷ Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.
⁸ Laboratory of Hematology, University Hospital Saint-Louis, Université de Paris, Paris, France.
⁹ Department of Genetics and Research Centre, Portuguese Oncology Institute of Porto, Porto, Portugal.
¹⁰ Department of Molecular Hemato-Oncology, LHUB-ULB, Brussels, Belgium.
¹¹ Pathology Department, Hospital Clinic, Institut d' Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERONC, Barcelona, Spain.
¹² Fundeni Clinical Institute, Hematology Department, Bucharest, Romania.
¹³ Hematology Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
¹⁴ Laboratório de Hemato-Oncologia-LHO Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal.
¹⁵ Institute for Hematology and Oncology (IHO GmbH), Mannheim, Germany.
¹⁶ University Hospital of Bordeaux, Laboratory of Hematology, Haut Lévêque Hospital, Pessac, France.
¹⁷ Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
¹⁸ University of Leipzig Medical Center, Department for Hematology, Cellular Therapies and Hemostaseology, Leipzig, Germany.
¹⁹ Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
²⁰ Poznan University of Medical Sciences, Department of Hematology and Bone Marrow Transplantation, Poznan, Poland.
²¹ Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain.
²² Laboratory of Chemical and Clinical Analysis "Area 3" A.O.U San Luigi Gonzaga-Orbassano, Turin, Italy.
²³ SIHMDS Hosted by Imperial College Healthcare NHS Trust at Hammersmith Hospital, London, UK.
²⁴ Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'Hématologie Biologique, Pierre-Bénite, France.
²⁵ Section of Molecular Diagnostics, Clinical Genetics, Region Skåne, Lund, Sweden.
²⁶ Ritus Biotec Laboratory, Codlea-Brasov, Romania.
²⁷ Transilvania University, Brasov, Romania.
²⁸ Department of Molecular Medicine and Medical Biotechnology University 'Federico II' and CEINGE-Advanced Biotechnologies, Naples, Italy.
²⁹ Hematology Department, Hospital Regional Universitario de Málaga, IBIMA, Málaga, Spain.
³⁰ Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic.
³¹ Faculty of Medicine, Masaryk University, Brno, Czech Republic.
³² Department of Genomics, Turku University Hospital Laboratories, Turku, Finland.
³³ Cancer Molecular Diagnostics, St. James's Hospital, Dublin, Ireland.
³⁴ Labdia Labordiagnostik/St. Anna Children´s Cancer Research Institute (CCRI), Vienna, Austria.
³⁵ Laboratory of Molecular Genetics, Central Hospital of Southern Pest National Institute of Hematology and Infectious Diseases, Budapest, Hungary.
³⁶ Pathology Department, University Clinical Center Tuzla, Policlinic for Laboratory Diagnostics, Tuzla, Bosnia and Herzegovina.
³⁷ Department of Medical Genetics, National Cancer Institute, Bratislava, Slovakia.
³⁸ Medical University of Vienna, Department of Laboratory Medicine, Vienna, Austria.
³⁹ MLL Munich Leukemia Laboratory, Munich, Germany.
⁴⁰ III. Medizinische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany.
⁴¹ CHU Lille, Laboratoire d'hématologie, F-59000, Lille, France.
⁴² University Hospital Bern, Bern, Switzerland.
⁴³ University of Bern, Bern, Switzerland.
⁴⁴ Haematology Research Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
⁴⁵ Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
⁴⁶ Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
⁴⁷ Second Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
⁴⁸ Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041, Madrid, Spain.
⁴⁹ Hematological Malignancies Clinical Research Unit, CNIO, 28029, Madrid, Spain.
⁵⁰ Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029, Madrid, Spain.
⁵¹ West Midlands Regional Genetics Laboratory, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
⁵² Abteilung Hämatologie/Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany.
⁵³ Molecular Diagnostics Laboratory, Hematology Department and HCT Unit, George Papanicolaou General Hospital, Thessaloniki, Greece.
⁵⁴ HemoDiagnostic Laboratory, Department of Hematology, Aarhus University Hospital, Aarhus, Denmark.
⁵⁵ Amsterdam University Medical Center, Amsterdam, The Netherlands.
⁵⁶ IRCSS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli", Bologna, Italy.
⁵⁷ Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University of Catania, Catania, Italy.
⁵⁸ Molecular Hemapathology, Oslo University Hospital, Oslo, Norway.
⁵⁹ Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals, Leeds, UK.
⁶⁰ University Hospital Center Zagreb, Zagreb, Croatia.
⁶¹ The University Hospital in Krakow, Krakow, Poland.
⁶² Institute of Hematology and Blood Transfusion, Prague, Czech Republic.
⁶³ Faculty of Medicine, University of Southampton, Southampton, UK. ncpc@soton.ac.uk.
⁶⁴ Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury, UK. ncpc@soton.ac.uk.

PMID: 35614319
PMCID: PMC9252906
DOI: 10.1038/s41375-022-01607-z

Standardization of molecular monitoring of CML: results and recommendations from the European treatment and outcome study

Helen E White et al. Leukemia. 2022 Jul.

. 2022 Jul;36(7):1834-1842.

doi: 10.1038/s41375-022-01607-z. Epub 2022 May 25.

Authors

Affiliations

¹ Faculty of Medicine, University of Southampton, Southampton, UK.
² Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury, UK.
³ Department of Emergency and Organ Transplantation (D.E.T.O.)-Hematology and Stem Cell Transplantation Unit, University of Bari "Aldo Moro", Bari, Italy.
⁴ Department of Pathology, Zealand University Hospital, Roskilde, Denmark.
⁵ Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
⁶ Laboratory of Medical Genetics National Specialized Hospital for Active Treatment of Hematological Diseases, Sofia, Bulgaria.
⁷ Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.
⁸ Laboratory of Hematology, University Hospital Saint-Louis, Université de Paris, Paris, France.
⁹ Department of Genetics and Research Centre, Portuguese Oncology Institute of Porto, Porto, Portugal.
¹⁰ Department of Molecular Hemato-Oncology, LHUB-ULB, Brussels, Belgium.
¹¹ Pathology Department, Hospital Clinic, Institut d' Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERONC, Barcelona, Spain.
¹² Fundeni Clinical Institute, Hematology Department, Bucharest, Romania.
¹³ Hematology Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
¹⁴ Laboratório de Hemato-Oncologia-LHO Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal.
¹⁵ Institute for Hematology and Oncology (IHO GmbH), Mannheim, Germany.
¹⁶ University Hospital of Bordeaux, Laboratory of Hematology, Haut Lévêque Hospital, Pessac, France.
¹⁷ Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
¹⁸ University of Leipzig Medical Center, Department for Hematology, Cellular Therapies and Hemostaseology, Leipzig, Germany.
¹⁹ Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
²⁰ Poznan University of Medical Sciences, Department of Hematology and Bone Marrow Transplantation, Poznan, Poland.
²¹ Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain.
²² Laboratory of Chemical and Clinical Analysis "Area 3" A.O.U San Luigi Gonzaga-Orbassano, Turin, Italy.
²³ SIHMDS Hosted by Imperial College Healthcare NHS Trust at Hammersmith Hospital, London, UK.
²⁴ Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'Hématologie Biologique, Pierre-Bénite, France.
²⁵ Section of Molecular Diagnostics, Clinical Genetics, Region Skåne, Lund, Sweden.
²⁶ Ritus Biotec Laboratory, Codlea-Brasov, Romania.
²⁷ Transilvania University, Brasov, Romania.
²⁸ Department of Molecular Medicine and Medical Biotechnology University 'Federico II' and CEINGE-Advanced Biotechnologies, Naples, Italy.
²⁹ Hematology Department, Hospital Regional Universitario de Málaga, IBIMA, Málaga, Spain.
³⁰ Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic.
³¹ Faculty of Medicine, Masaryk University, Brno, Czech Republic.
³² Department of Genomics, Turku University Hospital Laboratories, Turku, Finland.
³³ Cancer Molecular Diagnostics, St. James's Hospital, Dublin, Ireland.
³⁴ Labdia Labordiagnostik/St. Anna Children´s Cancer Research Institute (CCRI), Vienna, Austria.
³⁵ Laboratory of Molecular Genetics, Central Hospital of Southern Pest National Institute of Hematology and Infectious Diseases, Budapest, Hungary.
³⁶ Pathology Department, University Clinical Center Tuzla, Policlinic for Laboratory Diagnostics, Tuzla, Bosnia and Herzegovina.
³⁷ Department of Medical Genetics, National Cancer Institute, Bratislava, Slovakia.
³⁸ Medical University of Vienna, Department of Laboratory Medicine, Vienna, Austria.
³⁹ MLL Munich Leukemia Laboratory, Munich, Germany.
⁴⁰ III. Medizinische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany.
⁴¹ CHU Lille, Laboratoire d'hématologie, F-59000, Lille, France.
⁴² University Hospital Bern, Bern, Switzerland.
⁴³ University of Bern, Bern, Switzerland.
⁴⁴ Haematology Research Laboratory, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
⁴⁵ Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
⁴⁶ Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia.
⁴⁷ Second Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
⁴⁸ Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041, Madrid, Spain.
⁴⁹ Hematological Malignancies Clinical Research Unit, CNIO, 28029, Madrid, Spain.
⁵⁰ Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029, Madrid, Spain.
⁵¹ West Midlands Regional Genetics Laboratory, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
⁵² Abteilung Hämatologie/Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany.
⁵³ Molecular Diagnostics Laboratory, Hematology Department and HCT Unit, George Papanicolaou General Hospital, Thessaloniki, Greece.
⁵⁴ HemoDiagnostic Laboratory, Department of Hematology, Aarhus University Hospital, Aarhus, Denmark.
⁵⁵ Amsterdam University Medical Center, Amsterdam, The Netherlands.
⁵⁶ IRCSS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli", Bologna, Italy.
⁵⁷ Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University of Catania, Catania, Italy.
⁵⁸ Molecular Hemapathology, Oslo University Hospital, Oslo, Norway.
⁵⁹ Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals, Leeds, UK.
⁶⁰ University Hospital Center Zagreb, Zagreb, Croatia.
⁶¹ The University Hospital in Krakow, Krakow, Poland.
⁶² Institute of Hematology and Blood Transfusion, Prague, Czech Republic.
⁶³ Faculty of Medicine, University of Southampton, Southampton, UK. ncpc@soton.ac.uk.
⁶⁴ Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury, UK. ncpc@soton.ac.uk.

PMID: 35614319
PMCID: PMC9252906
DOI: 10.1038/s41375-022-01607-z

Abstract

Standardized monitoring of BCR::ABL1 mRNA levels is essential for the management of chronic myeloid leukemia (CML) patients. From 2016 to 2021 the European Treatment and Outcome Study for CML (EUTOS) explored the use of secondary, lyophilized cell-based BCR::ABL1 reference panels traceable to the World Health Organization primary reference material to standardize and validate local laboratory tests. Panels were used to assign and validate conversion factors (CFs) to the International Scale and assess the ability of laboratories to assess deep molecular response (DMR). The study also explored aspects of internal quality control. The percentage of EUTOS reference laboratories (n = 50) with CFs validated as optimal or satisfactory increased from 67.5% to 97.6% and 36.4% to 91.7% for ABL1 and GUSB, respectively, during the study period and 98% of laboratories were able to detect MR^4.5 in most samples. Laboratories with unvalidated CFs had a higher coefficient of variation for BCR::ABL1^IS and some laboratories had a limit of blank greater than zero which could affect the accurate reporting of DMR. Our study indicates that secondary reference panels can be used effectively to obtain and validate CFs in a manner equivalent to sample exchange and can also be used to monitor additional aspects of quality assurance.

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Conflict of interest statement

HW has received honoraria from Novartis. SS has received honoraria from Incyte, Novartis, Pfizer, Bristol Myers Squibb, and Roche and research support from Incyte, Novartis, and Bristol Myers Squibb. J-MC has received research support and honoraria from Incyte, and honoraria from Novartis and Cepheid. TL has received honoraria from Incyte, Novartis, Pfizer, Angelini, Bristol Myers Squibb, and research support from Incyte, Novartis, and Pfizer. PV has received honoraria from Astra-Zeneca, Eli Lilly, Gilead; GlaxoSmithKline, Novartis, Pfizer, Roche, Teva, and research support from Novartis and Pfizer. SM is employed by the MLL Munich Leukemia Laboratory GmbH, Munich. CD and MM are employed by the Institute for Hematology and Oncology (IHO GmbH), Mannheim. KMP has received honoraria from Angelini and Incyte. AH received research support from Novartis, BMS, Pfizer, and Incyte. NC has received research support and honoraria from Novartis, and honoraria from Incyte and Astellas.

Figures

**Fig. 1. Ability of laboratories to detect MR^4.5.**
Overall laboratory scores per reference gene were defined as green (detects MR^4.5 in a high proportion of samples, combined score > 80%), amber (detects MR^4.5 in most samples, combined score > 60%) or red (unable to detect MR^4.5 in most samples, combined score < 60%). The bar charts show the number of data sets in each category for all laboratories. Several laboratories submitted data for more than one reference gene or assay and therefore the number of data sets analysed is greater than the number of participating laboratories.

**Fig. 2. Stability of CFs for laboratories using *ABL1* as a reference gene.**
CFs were calculated and provided to laboratories on an annual basis. The stability of each CF was determined as either optimal (bright green), satisfactory (green) or unvalidated (amber) by comparison with the previous year’s value using the following criteria; Optimal (+/− 1.2 fold): Old CF/New CF = 0.83–1.2, Satisfactory (+/− 1.6 fold): Old CF/New CF = 0.63–1.58 or Unvalidated: Old CF/New CF < 0.63 or >1.58. The bars charts show the number of laboratories for each category, per year for *ABL1* reference gene data sets. Several laboratories submitted data for more than one assay and therefore the number of data sets analysed may be greater than the number of participating laboratories.

**Fig. 3. Stability of CFs for laboratories using *GUSB* as a reference gene.**
CFs were calculated and provided to laboratories on an annual basis. The stability of each CF was determined as either optimal (bright green), satisfactory (green) or unvalidated (amber) by comparison with the previous year’s value using the following criteria; Optimal (+/− 1.2 fold): Old CF/New CF = 0.83–1.2, Satisfactory (+/− 1.6 fold): Old CF/New CF = 0.63–1.58 or Unvalidated: Old CF/New CF < 0.63 or >1.58. The bars charts show the number of laboratories for each category, per year for *GUSB* reference gene data sets. Several laboratories submitted data for more than one reference gene or assay and therefore the number of data sets analysed may be greater than the number of participating laboratories.

**Fig. 4. Use of IQC material to assess how CFs correlate with assay variability.**
CVs for BCR::ABL1^IS results from high and low level internal quality control material were used to assess how assay variability might correlate with CF status (optimal, 37% of laboratories who tested the internal quality control material; satisfactory, 35% of laboratories; unvalidated, 21% of laboratories). Combined variability scores for the high and low standards were assigned using the following criteria: 3 points: CV < 1st quartile, 2 points: CV between 1st quartile and median, 1 point: CV between median and 3rd quartile. 0 points: CV > 3rd quartile. The overall variability score (CbVar) was defined as the sum of the scores for the high and low level standards. The bar charts show the % of laboratories per CF status that had a combined variability scores of 6 (bright green). 4 or 5 (green), 2 or 3 (amber) or 1/0 (red).

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References

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Standardization of molecular monitoring of CML: results and recommendations from the European treatment and outcome study

Affiliations

Standardization of molecular monitoring of CML: results and recommendations from the European treatment and outcome study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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LinkOut - more resources

Full Text Sources

Medical

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