Using Next Generation Sequencing to Identify Trackable Clonotypic Sequences for Minimal Residual Disease Testing in AL Amyloidosis

Introduction: Recent studies have shown that deeper free light chain responses are associated with improved outcomes in patients with systemic light chain (AL) amyloidosis, yet the optimal long-term goal remains unclear.(N Engl J Med 2018; 378:518-528) Unlike multiple myeloma, where the role of minimal residual disease (MRD) testing is well established, in AL amyloidosis the methods to best identify MRD, and whether achieving MRD would benefit disease outcomes, warrant further investigation. (Blood Cancer J. 2021 Jun 21;11(6):117; PLoS ONE 15(7): e0235713. https://doi.org/10.1371/journal.pone. 0235713) In AL amyloidosis, the toxic misfolded oligomers and amyloid deposits are both due to clonal immunoglobulin light chains and cause organ damage and death. Hence, the tracking of clonotypic light chain sequences could present a promising approach for detecting the maintenance of profound therapeutic responses. Our study aimed to assess the frequency with which next generation sequencing (NGS) detects light-chain clones consistent with the patient’s clonal light-chain isotype and to determine whether the light-chain sequences identified were encoded by light-chain variable region genes considered AL-related.(Journal of Clinical Oncology 2019 37:15_suppl, 8010; Blood (2017) 129 (3): 299–306; PLoS One 2022 Feb 25;17(2):e0264407)

Methods: Ninety patients diagnosed with AL amyloidosis between September 2016 and July 2023 at Tufts Medical Center and University of California San Francisco were included. Bone marrow samples from the 90 patients were sent to Adaptive Biotechnologies Inc. (Seattle, WA) for initial clone identification using the clonoSEQ Assay. IMGT/BlastSearch database (Version 1.2.1) was used to identify the clonotypic immunoglobulin light chain variable domains detected by the clonoSEQ assay. Samples were then divided in to two groups based on the consistency of paraprotein isotype with the trackable sequences, and Mann-Whitney U test was used to compare the difference of the numbers of clonotypic sequences.

Results: Of the 90 patients with bone marrow samples sent for clone identification, 85 (94.4%) had at least one trackable clonotypic sequence, with a median number of 3 and a maximum of 11. Of the 85 patients with trackable sequences, 67 (78.8%) had an AL paraprotein isotype consistent with the detected clonotypic sequence isotype, 48 with light chain and 19 with heavy chain isotypes. Compared to the inconsistent ones, patients who had consistency in paraprotein and trackable sequences exhibited higher numbers of clonotypic sequences (P = 0.001). With respect to marrow plasma cell infiltrations, both consistent and inconsistent groups had a median of 15% marrow plasma cells with no statistically significant difference between them by two-tailed Mann-Whitney. Of note, consistent with the restricted pattern of germline gene use in AL, the 48 patients also used AL-related variable region Ig light chain genes; the variable region light chain genes identified were AL-related and included IGKV1-33 (8 identified sequences), IGKV4-1 (4), IGKV1-16 (3), IGKV1-5 (1), GKV1-13 (1), IGLV6-57 (8), IGLV3-21 (6), IGLV1-44 (5), IGLV3-1 (4), IGLV1-40 (3), IGLV2-14 (3), IGLV1-51 (2).

Conclusion: In patients with AL amyloidosis, the ClonoSEQ assay can identify a sequence consistent with the patient’s light or heavy chain isotype almost 80% of the time. Of those cases in which a clonal light chain sequence was consistent with the patient’s isotype, the genes identified were from the well described AL-related light chain variable region gene repertoire. These findings indicate that the size of the AL clone does not affect this outcome and suggest that other factors related to the adaptive immune dysregulation of AL or to the multiplex PCR process may be involved. ClonoSEQ can identify trackable clonotypic light chain sequences that are AL-related 56% of the time in patients with AL, a finding that may be relevant to patients with myeloma.