Description:

In spite of an explosion of data regarding mutations occurring in childhood ALL, along with reports of poor survival associated with the presence of one or more key mutations or defined gene expression profiles, there is controversy about when molecular analyses should drive therapy. Clinical parameters at presentation (WBC, age, T- vs. B-lineage, etc.) have dictated initial risk stratification. However, studies over the past decade have demonstrated that leukemic response measured by minimal residual disease (MRD, either PCR- or flow cytometry-based) has been the single most important factor in determining relapse risk, and current protocols increase or decrease therapeutic intensity based upon MRD measurements early in therapy. Experience with Ph+ ALL has demonstrated that it is possible to improve outcome with agents targeted at small subsets of patients, and efforts are under way to define molecular subgroups that might benefit from the addition of targeted agents. This session will attempt to define when MRD vs. genomic, transcriptional or epigenomic alterations should drive therapy.

Dr. Michael Pulsipher will describe the effect that disease response measured by MRD has on outcomes, including data using PCR and flow cytometry approaches as well as emerging data with next-generation sequencing (NGS) MRD. He will address the effect of timing and level of MRD on outcomes after chemotherapy and BMT, and show how significant MRD response can overcome many high-risk mutations.

Dr. Andrea Biondi will show the latest data on genomic mutations and their effect on survival. He will also describe current efforts aimed at targeting specific mutations, and suggest times when patients may benefit from adding targeted agents to their therapy.

Dr. Kathrin Bernt will focus on emerging data regarding the role of epigenetic alterations in ALL outcomes and describe the potential future role of interventions aimed at patients with these alterations.