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PCR via Peripheral Blood vs Bone Marrow


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#1 jenz

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Posted 19 July 2011 - 10:56 AM

All:

I have read numerous conflicting things that say bone marrow is the gold seal for PCR, Kerotyping, and FISH testing.  Then others I have read say that you can do all of it from peripheral blood once the marrow is clean (0%).  I have also been told that you cannot compare PCR results that were done from PB from results of Bone Marrow? While other places say that you can.  So now I have myself all confused.  My primary oncologist says she does not trust results from PB and only makes decision from bone marrow which is making it difficult when I got recent results from PB that showed signifcant decrease.  So far from PB my results have been the following. 

11/09/10 - BCR-ABL Ratio       1.17

01/17/11 - BCR-ABL Ratio      0.51

04/15/11 - BCR-ABL Ratio      0.74

07/11/11 - BCR-ABL Ratio      0.082  (Latest result)

The big difference from April to July is that in June I switched to Tasigna from Gleevec.  So I attribute the significant decrease to Tasigna.

I want to be happy about this but I am struggling with the fact this is from peripheral blood and not marrow.

Jen



#2 Trey

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Posted 19 July 2011 - 11:19 AM

PCR is the closest of these tests between blood and marrow.  FISH is less accurate from blood.  Cytogenetic karyotyping is not done from peripheral blood.



#3 LivingWellWithCML

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Posted 19 July 2011 - 11:30 AM

Jen,

The CML specialist I'm seeing is Dr. Hanna Khoury at Emory Winship Cancer Institute in Atlanta.  He is monitoring my treatment exclusively through PB, and he co-authored a study in late 2010 that did a direct comparison of PB and bone marrow as monitoring techniques:

http://onlinelibrary....25678/abstract

I haven't purchased the research study (because I'm not a hematologist!), but here's the summary.  In short, the authors concluded that PB FISH and PB Q-PCR are reliable and correlate very closely to bone marrow - the summary data below does support that conclusion.  With that said, I'm mildly debating whether I should beg for a BMB/A at 6 months.  I brought it up with him at my last appointment and he told me that I'm the first patient that was actually **asking** for BMB <laugh>.  He seems very confident in PB, and he is on the small list of CML specialists in the US, so I have a lot of trust in his recommendation ... especially given his focus on CML.

I'm curious what others on this board are hearing from their CML specialists?

_______________________________________

Abstract

BACKGROUND:

The current study was conducted to compare simultaneously obtained bone marrow (BM) cytogenetics (CTG), peripheral blood (PB) and BM fluorescence in situ hybridization (FISH), and quantitative real-time polymerase chain reaction (Q-PCR) for BCR-ABL1 in monitoring response to treatment with tyrosine kinase inhibitors and homoharringtonine (HHT) in patients with chronic myeloid leukemia (CML).

METHODS:

PB and BM FISH (n = 112 samples) and/or Q-PCR (n = 132 samples) for BCR-ABL1 were simultaneously obtained in 70 patients with Philadelphia chromosome-positive (Ph+) CML in chronic (68%), accelerated (16%), and blast phase (16%) before the initiation of therapy and during the course of treatment with imatinib (IM) (n = 40 patients), dasatinib (n = 20 patients), nilotinib (n = 4 patients), bosutinib (n = 18 patients), or HHT (n = 4 patients) for patients with newly diagnosed (n = 13 patients), IM-sensitive (n = 34 patients), IM-resistant (n = 30 patients), or IM-intolerant (n = 9 patients) disease. Eighteen patients were found to have Ph+ variants or karyotypic abnormalities in addition to the Ph+.

RESULTS:

Excellent correlations ® were observed between PB and BM FISH (r = 0.95) and PB and BM Q-PCR (r = 0.87), as well as BM CTG and PB FISH (r = 0.89) and PB Q-PCR (r = 0.82). This correlation was not affected by the presence of the Ph+ variant or additional chromosomal abnormalities, the presence of ABL1 kinase domain mutations, phase of the disease, or treatment.

CONCLUSIONS:

PB FISH and Q-PCR appear to be reliable methods with which to monitor response to modern therapy in patients with all phases of CML. Cancer 2011. © 2010 American Cancer Society.


Dan - Atlanta, GA

CML CP Diagnosed March 2011

Gleevec 400mg


#4 CallMeLucky

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Posted 19 July 2011 - 02:30 PM

While BM and PB may vary a bit when doing a direct comparison, there is no doubt that your results show excellent progress and you are heading in the direction you need to.  You should be very happy with these results.


Date  -  Lab  -  Scale  -  Drug  -  Dosage MG  - PCR
2010/Jul -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 1.2%
2010/Oct -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0.25%
2010/Dec -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0.367%
2011/Mar -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0.0081%
2011/Jun -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0%
2011/Sep -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0.00084%
2011/Dec -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0%
2012/Mar -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0.004%
2012/Jun -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0%
2012/Sep -  MSKCC  -  Non-IS  -  Gleevec  - 400 - 0%
2012/Dec -  MSKCC  -  Non-IS  -  Sprycel  - 100 - 0%
2013/Jan -  Quest  -  IS  -  Sprycel  -  50-60-70  - 0%
2013/Mar -  Quest  -  IS  -  Sprycel  -  60-70  - 0%
2013/Apr -  CUMC  -  Non-IS  -  Sprycel  - 50 - 0.036%
2013/May -  CUMC  -  Non-IS  -  Sprycel  - 50 - 0.046%
2013/Jun -  Genoptix  -  IS  -  Sprycel  - 50 - 0.0239%
2013/Jul -  Genoptix  -  IS  -  Sprycel  - 70 - 0.0192%
2013/Jul -  Genoptix  -  IS  -  Sprycel  - 70 - 0.0034%
2013/Oct -  Genoptix  -  IS  -  Sprycel  - 70 - 0.0054%
2014/Jan -  Genoptix  -  IS  -  Sprycel  - 70 - 0.0093%
2014/Mar -  Genoptix  -  IS  -  Sprycel  - 100 - 0.013%
2014/Apr -  Genoptix  -  IS  -  Sprycel  - 100 - 0.0048%
2014/Jul -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2014/Nov -  Genoptix  -  IS  -  Sprycel  - 100 - 0.047%
2014/Dec -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2015/Mar -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2015/Jun -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2015/Sep -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2015/Dec -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2016/Mar -  Genoptix  -  IS  -  Sprycel  - 100 - 0.0228%
2016/Jun -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2016/Sep -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2016/Dec -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2017/Mar -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2017/Jun -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2017/Sep -  Genoptix  -  IS  -  Sprycel  - 100 - 0%
2017/Dec - Genoptix  -  IS  -  Sprycel  -  100 - 0%
 

 


#5 Steve-o

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Posted 19 July 2011 - 05:58 PM

My Onc is also in the camp with Dan's doctor.  I brought this up at diagnosis and she said that it is "somewhat controversial."  Kind of an old school versus new school line of thinking.  She said that she would do a BMB if I insisted but did not feel it was necessary.  I didn't insist and did not have a BMB at diagnosis.  She did say that she plans to do one at 6 months.  I've been on Gleevec since June 8th.  I do blood work weekly and my counts have been in the normal range for the last two weeks.



#6 jenz

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Posted 19 July 2011 - 06:25 PM

OK, So tonight I finally put my results into excel to try to make sense of the difference in results from PB to BM.  Check out how much of a difference is from PB to BM particular on 11/8/10 date..  PB tends to show a steady down turn while the BM results tends to have some ups and downs to it. 

BCR- ABL Results

DateFacilitySourceResult




11/8/10University of ChicagoBone Marrow1.9
12/27/10University of ChicagoBone Marrow1.12
2/14/11University of ChicagoBone Marrow0.979
5/16/11University of ChicagoBone Marrow1.297




11/8/10University of ChicagoPeripherial Blood1.157
1/17/11University of ChicagoPeripherial Blood0.51
4/15/11University of ChicagoPeripherial Blood0.743
7/11/11University of ChicagoPeripherial Blood0.082

It is obvious from PCR testing that Gleevec was not doing the trick for me. 

But when you look at the FISH results during the same time period then the question of Gleevec working is questionable??

FISH   Results






DateFacilitySourceResult
11/9/10University of ChicagoBone Marrow90%
12/17/10University of ChicagoBone Marrow83%
2/14/11University of ChicagoBone Marrow63%
5/16/11University of ChicagoBone Marrow51%


#7 LivingWellWithCML

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Posted 19 July 2011 - 08:42 PM

And on my end, Khoury did have a BMB/A done at diagnosis in order to verify chronic phase.

Jen - have they done any PB FISH testing for you, or has FISH exclusively been done on marrow as you're showing?  I had FISH on marrow at diagnosis, then 6 week and 3 month FISH on PB only.  And plans are to continue FISH/Q-PCR on PB moving forward [unless I ask for otherwise, I suppose]).


Dan - Atlanta, GA

CML CP Diagnosed March 2011

Gleevec 400mg


#8 jenz

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Posted 20 July 2011 - 10:23 AM

All my FISH have been from bone marrow, never PB.

OK, Looking further at my latest PCR report I am trying to make sense of what I am reading.


"This assay can detected one postive cell in 10,000 to 100,000 normal cells. Quantitive real-time PCR also shows a bcr-abl translocation IS present"

BCR-ABL Transcript

P210     3,520 copies/reaction

P190     None Detected

C-ABL transcript 42,750 copies/reaction

BCR-ABL/C-ABL Ratio 0.082

Are C-ABL normal cells?  So 3,520 P210 were found out of 42,750? When divided you get the 0.082 number...



#9 LivingWellWithCML

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Posted 20 July 2011 - 10:41 AM

I think that "C" stands for the control gene -- that's what they use to measure the ratio in PCR, so you're looking at the right number.  Did they do FISH in July as well?  Based on that PCR decrease, you would think that your FISH would be 0% or close to it.


Dan - Atlanta, GA

CML CP Diagnosed March 2011

Gleevec 400mg


#10 PhilB

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Posted 20 July 2011 - 10:51 AM

Oh how I wish everyone would go onto the international scale and standardised reporting.

People may have been getting confused on this one because normally all PCRs get reported as a percentage, but yours are being done as a ratio instead so eg your 0.082 is actually 8.2%  This makes the PCR numbers much more in line with what the FISH was showing.  Although if they are reporting ratios they probably aren't converting to International Scale either.

It's good to see the nice reduction since you swapped drugs.  All now looks to be heading the right way.

Phil



#11 jenz

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Posted 20 July 2011 - 01:11 PM

OK, This is the last post for awhile.  Just to make sure I am understanding correctly.  A 1 log reduction is a 10 fold decrease.  So these should be my goals over time if that is the case.. Can someone confirm this is right thought process?  These of course are NOT using the international scale, just taking into account my dx number and reducing 10 fold each time..

Diagnosis1.9
1 log reduction0.19
2 log reduction0.019
3 log reduction0.0019


#12 Trey

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Posted 20 July 2011 - 01:16 PM

c-ABL is the "normal" form of the gene.  It is also called ABL1, and the long form name is "c-abl oncogene 1".  So the c-ABL (ABL1) is used as the normal control gene to ensure the abnormal gene (BCR-ABL) is properly ratioed.  Otherwise the BCR-ABL raw number in isolation would not mean anything since it must be related to something "normal" from the sample.

So the PCR number you care about is the percentage, which is 8.2%

Dan -- Good guess, but c-ABL does not mean "control".



#13 PhilB

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Posted 20 July 2011 - 01:19 PM

Sort of right.  The numbers you quote are indeed what you need for a 3 log reduction from your value at dx.  It's probably more relevant though to know what a 3 log reduction from your labs average / the IS baseline is as this is what's really used practically to define MMR - otherwise the earlier you were diagnosed the deeper the response you'd need.  Take a look at my post on page 13 of Roll call.

regards

Phil



#14 Trey

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Posted 20 July 2011 - 01:25 PM

Math is correct, but for log reduction purposes make sure these are consistently the same thing, i.e., either consistently ratios or consistently percentages.  Your recent 8.2% does not track with the "1.9" which may be a ratio (and the percentage would be 190%).  But if ratios, the current ratio of .082 means you are very roughly halfway to MMR.  So it is important to get the numbers straight (WHICH YOUR ONC SHOULD BE DOING FOR YOU OR ELSE HE IS FAILING YOU).

Or you could use International Scale if your lab uses it, which should provide you with a standardized log reduction per Phil's comments.  Either way if your Onc is not giving you enough info, ask the question very directly and demand a direct answer.



#15 jenz

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Posted 20 July 2011 - 01:38 PM

Trey,

Thanks your input is always much appreciated. 

You are absolutely correct, the 1.9 RATIO came from my bone marrow results not peripheral blood.  To keep the numbers straight since the .082 result was from PB.  Then this would be the tracking for PCR reductions from PB for me.  You are correct I plan on having a discussion with my oncologist about this.  I would love to know the factor multiplier difference between U. of Chicago and the International Scale.

Diagnosis1.157
1 log reduction0.1157
2 log reduction0.01157
3 log reduction0.001157


#16 Dsrwbr4536

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Posted 20 July 2011 - 08:34 PM

Ok sorry to butt in but went to see onc today. Bcr- abl is at 0.337. So from what I am understanding this is not as good as we thought?



#17 LivingWellWithCML

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Posted 21 July 2011 - 08:54 AM

Hey everyone,

This is a really helpful thread -- thanks for all of the guidance.  And Jen - thanks for posing these questions around your case!

I am preparing to review my first PB PCR (3 months into Gleevec 400mg), and I want to make sure I've got this right as well.  Apologies for any questions that have been asked over and over again.

** Interpretation of PCR :: I'm looking at my PCR from dx (done from BM) and this is all that the results show - nothing more.  This was run on-site at Emory Winship.  What's the number that matters?  The Current Ratio?

  • Current Ratio = 0.25
  • Current Log Change from Baseline = 0.50
  • Current Percent = 312.50%

** International Scale :: What's the right way to phrase this question for the provider?  I cannot tell from the BM PCR if they applied any International conversion factor.  Perhaps that's what the Current Percent is?  How important is it that we apply this conversion factor for accurate monitoring of x-log reductions?

** PCR BM vs. PCR PB :: Is there any value in comparing the PCR BM at dx with the PCR PB at 3-months to draw an early conclusion on the response to Gleevec (or any TKI for that matter)?  Since they are planning to track PCR results exclusively with PB, is the 3-month value considered the true "baseline" for response monitoring?

Thanks in advance for any feedback.  I just want to make sure I'm well schooled for my upcoming appointment.

Dan


Dan - Atlanta, GA

CML CP Diagnosed March 2011

Gleevec 400mg





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