FDA IDE validation of multiple myeloma MRD test by flow cytometry

IF 10.1 1区 医学 Q1 HEMATOLOGY
Dragan Jevremovic, Min Shi, Pedro Horna, Gregory E. Otteson, Michael M. Timm, Shannon A. Bennett, Linda B. Baughn, Patricia T. Greipp, Wilson I. Gonsalves, Prashant Kapoor, Morie A. Gertz, Moritz Binder, Francis K. Buadi, Angela Dispenzieri, Taxiarchis Kourelis, Eli Muchtar, Jiehao Zhou, S. Vincent Rajkumar, Shaji K. Kumar, Horatiu Olteanu
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Second, after many years of deliberations, FDA announced on April 29, 2024 that it will start overseeing laboratory developed tests (LDTs).<span><sup>8</sup></span> LDTs are in vitro diagnostic products (IVDs) intended for clinical use; they are designed and validated for use within individual laboratories certified for performing high complexity testing under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The FDA's decision is currently being challenged by the American Clinical Laboratory Association.</p><p>The most commonly used assays for MRD detection in plasma cell neoplasms are next-generation sequencing (NGS) of the rearranged variable immunoglobulin heavy chain<span><sup>9, 10</sup></span> and high sensitivity flow cytometry immunophenotyping (next-generation flow, NGF).<span><sup>11-14</sup></span> Each type of assay has its advantages and disadvantages. For example, NGS requires knowledge of the diagnostic specimen for sequence comparison, but that knowledge enables higher sensitivity (10<sup>−6</sup>). NGF, as developed by the Euroflow/Spanish flow cytometry experts and commercialized by Cytognos requires no prior diagnostic specimen and can provide information regarding quality of the specimen (hemodilution); the sensitivity of the NGF is between 10<sup>−5</sup> and 2 × 10<sup>−6</sup>, depending on the number of cells (events) collected. In 2016, the International Myeloma Working Group established the minimum sensitivity of 10<sup>−5</sup> for MM MRD testing.<span><sup>4</sup></span></p><p>Currently the only FDA-approved test for MM MRD is NGS-based clonoSEQ® by Adaptive Biotechnologies.<span><sup>9</sup></span> For the NGF method to be FDA-approved, it will require a comprehensive package submission to the FDA, either as Premarket Approval (PMA) application or a Premarket Notification 510(k). However, FDA has a category of investigational device exemption (IDE) which allows a test to be used in a clinical study to collect safety and effectiveness data. There is limited data available regarding the requirements for FDA IDE approval of a flow cytometry assay for MRD testing.</p><p>In our laboratory, we adopted and validated the NGF method as an LDT, and have, since 2017, tested over 13 000 unique specimens (unpublished data). Our test validation protocol had been certified by CLIA and New York State Department of Health. However, when we submitted our validation documents as a part of the application for the FDA IDE for the BIQSFP-Funded Study EAA171, FDA requested additional validation experiments due to the fact that the MRD result was going to be used for MM patient stratification. After several meetings to precisely define additional requirements, we agreed with the FDA on the plan of action. Here we summarize additional experiments required by the FDA in order to approve IDE for the use of NGF in a clinical trial.</p><p><i>Analyte, specimen, and/or matrix stability</i>: Additional four bone marrow samples were stored in shipping containers at ambient temperature and tested after 24, 48, 72, and 96 h. Results from the accepted time points had to be qualitatively the same (MRD-positive or negative). The last acceptable time point was defined as the one in which the coefficient of variation (CV) ≤25%. The data showed that under ambient shipping condition, MRD detection can be confidently assessed up to 96 h post-draw (Table S1).</p><p><i>Precision/reproducibility</i>: Additional three MM samples were spiked into normal bone marrow samples, for calculated tumor burden between 5 × 10<sup>−6</sup> and 5 × 10<sup>−5</sup>. A total of eight replicates were performed for each sample. 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引用次数: 0

Abstract

Two recent decisions by the Food and Drug Administration will likely significantly impact testing for multiple myeloma (MM) minimal residual disease (MRD). First, on April 12, 2024, the FDA's Oncologic Drugs Advisory Committee (ODAC) voted to approve the use of MRD as an end point for accelerated approval of new treatments for patients with MM.1 This was a result of near 10 years effort by multiple institutions, professional societies, and patient's advocacy groups,2-6 and reflects the current state of MM treatment in which new therapeutic options have dramatically improved progression-free and overall survival (PFS and OS),7 making them impractical as the only clinical trial endpoints. Second, after many years of deliberations, FDA announced on April 29, 2024 that it will start overseeing laboratory developed tests (LDTs).8 LDTs are in vitro diagnostic products (IVDs) intended for clinical use; they are designed and validated for use within individual laboratories certified for performing high complexity testing under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The FDA's decision is currently being challenged by the American Clinical Laboratory Association.

The most commonly used assays for MRD detection in plasma cell neoplasms are next-generation sequencing (NGS) of the rearranged variable immunoglobulin heavy chain9, 10 and high sensitivity flow cytometry immunophenotyping (next-generation flow, NGF).11-14 Each type of assay has its advantages and disadvantages. For example, NGS requires knowledge of the diagnostic specimen for sequence comparison, but that knowledge enables higher sensitivity (10−6). NGF, as developed by the Euroflow/Spanish flow cytometry experts and commercialized by Cytognos requires no prior diagnostic specimen and can provide information regarding quality of the specimen (hemodilution); the sensitivity of the NGF is between 10−5 and 2 × 10−6, depending on the number of cells (events) collected. In 2016, the International Myeloma Working Group established the minimum sensitivity of 10−5 for MM MRD testing.4

Currently the only FDA-approved test for MM MRD is NGS-based clonoSEQ® by Adaptive Biotechnologies.9 For the NGF method to be FDA-approved, it will require a comprehensive package submission to the FDA, either as Premarket Approval (PMA) application or a Premarket Notification 510(k). However, FDA has a category of investigational device exemption (IDE) which allows a test to be used in a clinical study to collect safety and effectiveness data. There is limited data available regarding the requirements for FDA IDE approval of a flow cytometry assay for MRD testing.

In our laboratory, we adopted and validated the NGF method as an LDT, and have, since 2017, tested over 13 000 unique specimens (unpublished data). Our test validation protocol had been certified by CLIA and New York State Department of Health. However, when we submitted our validation documents as a part of the application for the FDA IDE for the BIQSFP-Funded Study EAA171, FDA requested additional validation experiments due to the fact that the MRD result was going to be used for MM patient stratification. After several meetings to precisely define additional requirements, we agreed with the FDA on the plan of action. Here we summarize additional experiments required by the FDA in order to approve IDE for the use of NGF in a clinical trial.

Analyte, specimen, and/or matrix stability: Additional four bone marrow samples were stored in shipping containers at ambient temperature and tested after 24, 48, 72, and 96 h. Results from the accepted time points had to be qualitatively the same (MRD-positive or negative). The last acceptable time point was defined as the one in which the coefficient of variation (CV) ≤25%. The data showed that under ambient shipping condition, MRD detection can be confidently assessed up to 96 h post-draw (Table S1).

Precision/reproducibility: Additional three MM samples were spiked into normal bone marrow samples, for calculated tumor burden between 5 × 10−6 and 5 × 10−5. A total of eight replicates were performed for each sample. CVs were calculated for comparisons of intra-assay, inter-assay, operator-to-operator, and instrument-to-instrument precision. Each replicate had to be qualitatively the same, with all the CVs ≤25%. Standardized machine settings and standardized gating strategy showed a highly precise assay near the assay's limit of detection (LOD) (Tables S2a and S2b).

Accuracy: Twenty-one MM samples were used to compare MRD results by NGF with NGS-based clonoSEQ® assay, using split sample procedure. Three samples were tested with two different concentrations of spiked abnormal cells. Additional 13 diagnostic specimens were also a part of this comparison. The results showed 100% concordance of NGF with clonoSEQ® NGS testing for MRD ≥10−5. In addition, 10 out of 10 NGF-positive cases with the sensitivity between 2 × 10−6 and 10−5 were confirmed positive by NGS. Four NGF-negative cases showed very low level of positivity by NGS (3–4 × 10−6) (Figure 1 and Table S3). Overall Pearson correlation coefficient was 0.83.

Analytical sensitivity/limit of detection: Four MM bone marrow samples were spiked into normal bone marrow to achieve calculated tumor burden of 10−3 (baseline), 10−4, 10−5, and 5 × 10−6 (half-log below the assay LOD), in triplicates, with expected CVs ≤25%. Two samples showed precise MRD-positive LOD down to 2 × 10−6, and the other two down to 10−5 (Tables S4a and S4b).

In summary, we describe a successful approval of the MM MRD test by NGF as an FDA IDE, to be used as a decision-making tool for patient stratification in a clinical trial (packet content with submitted studies/files is listed in Table S5). Two main requirements by the FDA were (I) to show reliable MRD testing at a half-log higher sensitivity than the stated LOD of the assay; and (II) to show direct correlation of the MRD results with the FDA-approved NGS test (which had been approved in the time between our original CLIA-test validation and the time of IDE submission). We were able to achieve excellent correlation between NGF and NGS on a split sample cohort of specimens. Our experience may help other laboratories with IDE submissions and test validation, particularly in the new era of FDA regulation of LDTs. Furthermore, data presented here may be of interest to professional societies and companies seeking a higher level of FDA approval for the NGF in MM MRD testing (PMA or Premarket Notification 510(k)), as well as to individual clinical laboratories looking to validate MM MRD test as an LDT in the era of FDA oversight.

DJ, SKK, MS, and HO designed the study. DJ, MS, GEO, and HO analyzed the data. DJ wrote the draft of the letter. MS, PH, GEO, MMT, LBB, PTG, WIG, PK, MAG, MB, FKB, JZ, AD, TK, EM, SVM, SKK, and HO critically reviewed the data and the letter.

The authors declare no conflicts of interest.

Abstract Image

多发性骨髓瘤流式细胞术 MRD 检测的 FDA IDE 验证
美国食品和药物管理局最近做出的两项决定可能会对多发性骨髓瘤(MM)最小残留病(MRD)检测产生重大影响。首先,2024 年 4 月 12 日,FDA 的肿瘤药物咨询委员会(ODAC)投票批准将 MRD 作为加速批准 MM 患者新疗法的终点。1 这是多家机构、专业协会和患者权益组织近 10 年努力的结果,2-6 反映了 MM 治疗的现状,即新的治疗方案极大地改善了无进展生存期和总生存期(PFS 和 OS)7,使其不适合作为唯一的临床试验终点。8 LDTs 是用于临床的体外诊断产品 (IVD);这些产品经过设计和验证,可在根据 1988 年《临床实验室改进修正案》(CLIA)获得执行高复杂性检测认证的实验室内使用。目前,美国临床实验室协会(American Clinical Laboratory Association)正在对 FDA 的决定提出质疑。浆细胞肿瘤 MRD 检测最常用的检测方法是重排可变免疫球蛋白重链的下一代测序(NGS)9、10 和高灵敏度流式细胞术免疫分型(下一代流式,NGF)11-14。例如,NGS 需要了解诊断标本以进行序列比对,但这种了解可提高灵敏度 (10-6)。由 Euroflow/西班牙流式细胞仪专家开发并由 Cytognos 商业化的 NGF 无需事先采集诊断标本,并可提供标本质量信息(血液稀释);NGF 的灵敏度介于 10-5 和 2 × 10-6 之间,具体取决于采集的细胞(事件)数量。2016 年,国际骨髓瘤工作组(International Myeloma Working Group)将 MM MRD 检测的最低灵敏度定为 10-5。4 目前,FDA 批准的唯一 MM MRD 检测方法是 Adaptive Biotechnologies 公司基于 NGS 的 clonoSEQ®。9 NGF 方法若要获得 FDA 批准,需要向 FDA 提交全面的包装申请,包括上市前批准 (PMA) 申请或上市前通知 510(k)。不过,FDA 有一类研究性设备豁免 (IDE),允许将测试用于临床研究,以收集安全性和有效性数据。关于 FDA IDE 批准用于 MRD 检测的流式细胞术检测的要求,目前可获得的数据有限。在我们的实验室,我们采用并验证了 NGF 方法作为一种 LDT,自 2017 年以来,已检测了超过 13 000 份标本(未发表数据)。我们的检测验证方案已获得 CLIA 和纽约州卫生部的认证。然而,当我们提交验证文件作为申请美国食品药品管理局(FDA)IDE的一部分,用于BIQSFP资助的EAA171研究时,FDA要求进行额外的验证实验,因为MRD结果将用于MM患者分层。为准确定义额外要求,我们召开了多次会议,最终与 FDA 就行动计划达成一致。在此,我们总结了 FDA 为批准在临床试验中使用 NGF 的 IDE 而要求进行的额外实验:另外四份骨髓样本储存在环境温度下的运输容器中,并在 24、48、72 和 96 小时后进行检测。可接受时间点的结果必须定性相同(MRD 阳性或阴性)。最后一个可接受的时间点被定义为变异系数(CV)≤25%的时间点。数据显示,在常温运输条件下,MRD检测可在抽样后96小时内进行可靠评估(表S1):另外在正常骨髓样本中添加了三个 MM 样品,计算出的肿瘤负荷在 5 × 10-6 和 5 × 10-5 之间。每个样本共进行了 8 次重复。计算的 CV 值用于比较测定内、测定间、操作者与操作者之间以及仪器与仪器之间的精密度。每个重复样本的质量必须相同,且所有 CV 值均小于 25%。标准化的机器设置和标准化的门控策略显示了接近检测限(LOD)的高精度检测(表 S2a 和 S2b):21 份 MM 样本采用分样程序,比较了 NGF 与基于 NGS 的 clonoSEQ® 检测法的 MRD 结果。三个样本使用两种不同浓度的加标异常细胞进行检测。另外 13 份诊断样本也参与了比较。结果显示,NGF 与 clonoSEQ® NGS 检测 MRD ≥10-5 的一致性为 100%。此外,在灵敏度介于 2 × 10-6 和 10-5 之间的 10 例 NGF 阳性病例中,有 10 例被 NGS 证实为阳性。
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来源期刊
CiteScore
15.70
自引率
3.90%
发文量
363
审稿时长
3-6 weeks
期刊介绍: The American Journal of Hematology offers extensive coverage of experimental and clinical aspects of blood diseases in humans and animal models. The journal publishes original contributions in both non-malignant and malignant hematological diseases, encompassing clinical and basic studies in areas such as hemostasis, thrombosis, immunology, blood banking, and stem cell biology. Clinical translational reports highlighting innovative therapeutic approaches for the diagnosis and treatment of hematological diseases are actively encouraged.The American Journal of Hematology features regular original laboratory and clinical research articles, brief research reports, critical reviews, images in hematology, as well as letters and correspondence.
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