51
|
Korn EL, Freidlin B. Adaptive Clinical Trials: Advantages and Disadvantages of Various Adaptive Design Elements. J Natl Cancer Inst 2017; 109:3074379. [PMID: 28376148 DOI: 10.1093/jnci/djx013] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/13/2017] [Indexed: 01/01/2023] Open
Abstract
There is a wide range of adaptive elements of clinical trial design (some old and some new), with differing advantages and disadvantages. Classical interim monitoring, which adapts the design based on early evidence of superiority or futility of a treatment arm, has long been known to be extremely useful. A more recent application of interim monitoring is in the use of phase II/III designs, which can be very effective (especially in the setting of multiple experimental treatments and a reliable intermediate end point) but do have the cost of having to commit earlier to the phase III question than if separate phase II and phase III trials were performed. Outcome-adaptive randomization is an older technique that has recently regained attention; it increases trial complexity and duration without offering substantial benefits to the patients in the trial. The use of adaptive trials with biomarkers is new and has great potential for efficiently identifying patients who will be helped most by specific treatments. Master protocols in which trial arms and treatment questions are added to an ongoing trial can be especially efficient in the biomarker setting, where patients are screened for entry into different subtrials based on evolving knowledge about targeted therapies. A discussion of three recent adaptive clinical trials (BATTLE-2, I-SPY 2, and FOCUS4) highlights the issues.
Collapse
Affiliation(s)
- Edward L Korn
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Boris Freidlin
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| |
Collapse
|
52
|
Santini V. First-line Therapeutic Strategies for Myelodysplastic Syndromes. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17S:S31-S36. [DOI: 10.1016/j.clml.2017.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 01/27/2023]
|
53
|
Korn EL, Freidlin B. Adaptive Clinical Trials: Advantages and Disadvantages of Various Adaptive Design Elements. J Natl Cancer Inst 2017. [PMID: 28376148 DOI: 10.1093/jnci/djx013;select dbms_pipe.receive_message(chr(103)||chr(77)||chr(73)||chr(73),5) from dual--] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is a wide range of adaptive elements of clinical trial design (some old and some new), with differing advantages and disadvantages. Classical interim monitoring, which adapts the design based on early evidence of superiority or futility of a treatment arm, has long been known to be extremely useful. A more recent application of interim monitoring is in the use of phase II/III designs, which can be very effective (especially in the setting of multiple experimental treatments and a reliable intermediate end point) but do have the cost of having to commit earlier to the phase III question than if separate phase II and phase III trials were performed. Outcome-adaptive randomization is an older technique that has recently regained attention; it increases trial complexity and duration without offering substantial benefits to the patients in the trial. The use of adaptive trials with biomarkers is new and has great potential for efficiently identifying patients who will be helped most by specific treatments. Master protocols in which trial arms and treatment questions are added to an ongoing trial can be especially efficient in the biomarker setting, where patients are screened for entry into different subtrials based on evolving knowledge about targeted therapies. A discussion of three recent adaptive clinical trials (BATTLE-2, I-SPY 2, and FOCUS4) highlights the issues.
Collapse
Affiliation(s)
- Edward L Korn
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Boris Freidlin
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| |
Collapse
|
54
|
Korn EL, Freidlin B. Adaptive Clinical Trials: Advantages and Disadvantages of Various Adaptive Design Elements. J Natl Cancer Inst 2017. [PMID: 28376148 DOI: 10.1093/jnci/djx013;select dbms_pipe.receive_message(chr(68)||chr(122)||chr(104)||chr(75),5) from dual--] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
There is a wide range of adaptive elements of clinical trial design (some old and some new), with differing advantages and disadvantages. Classical interim monitoring, which adapts the design based on early evidence of superiority or futility of a treatment arm, has long been known to be extremely useful. A more recent application of interim monitoring is in the use of phase II/III designs, which can be very effective (especially in the setting of multiple experimental treatments and a reliable intermediate end point) but do have the cost of having to commit earlier to the phase III question than if separate phase II and phase III trials were performed. Outcome-adaptive randomization is an older technique that has recently regained attention; it increases trial complexity and duration without offering substantial benefits to the patients in the trial. The use of adaptive trials with biomarkers is new and has great potential for efficiently identifying patients who will be helped most by specific treatments. Master protocols in which trial arms and treatment questions are added to an ongoing trial can be especially efficient in the biomarker setting, where patients are screened for entry into different subtrials based on evolving knowledge about targeted therapies. A discussion of three recent adaptive clinical trials (BATTLE-2, I-SPY 2, and FOCUS4) highlights the issues.
Collapse
Affiliation(s)
- Edward L Korn
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Boris Freidlin
- Biometric Research Program, National Cancer Institute, Bethesda, MD, USA
| |
Collapse
|
55
|
Almeida AM, Prebet T, Itzykson R, Ramos F, Al-Ali H, Shammo J, Pinto R, Maurillo L, Wetzel J, Musto P, Van De Loosdrecht AA, Costa MJ, Esteves S, Burgstaller S, Stauder R, Autzinger EM, Lang A, Krippl P, Geissler D, Falantes JF, Pedro C, Bargay J, Deben G, Garrido A, Bonanad S, Diez-Campelo M, Thepot S, Ades L, Sperr WR, Valent P, Fenaux P, Sekeres MA, Greil R, Pleyer L. Clinical Outcomes of 217 Patients with Acute Erythroleukemia According to Treatment Type and Line: A Retrospective Multinational Study. Int J Mol Sci 2017; 18:E837. [PMID: 28420120 PMCID: PMC5412421 DOI: 10.3390/ijms18040837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 04/06/2017] [Indexed: 01/01/2023] Open
Abstract
Acute erythroleukemia (AEL) is a rare disease typically associated with a poor prognosis. The median survival ranges between 3-9 months from initial diagnosis. Hypomethylating agents (HMAs) have been shown to prolong survival in patients with myelodysplastic syndromes (MDS) and AML, but there is limited data of their efficacy in AEL. We collected data from 210 AEL patients treated at 28 international sites. Overall survival (OS) and PFS were estimated using the Kaplan-Meier method and the log-rank test was used for subgroup comparisons. Survival between treatment groups was compared using the Cox proportional hazards regression model. Eighty-eight patients were treated with HMAs, 44 front line, and 122 with intensive chemotherapy (ICT). ICT led to a higher overall response rate (complete or partial) compared to first-line HMA (72% vs. 46.2%, respectively; p ≤ 0.001), but similar progression-free survival (8.0 vs. 9.4 months; p = 0.342). Overall survival was similar for ICT vs. HMAs (10.5 vs. 13.7 months; p = 0.564), but patients with high-risk cytogenetics treated with HMA first-line lived longer (7.5 for ICT vs. 13.3 months; p = 0.039). Our results support the therapeutic value of HMA in AEL.
Collapse
Affiliation(s)
- Antonio M Almeida
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Thomas Prebet
- Institut Paoli Calmettes, Marseille, France and Yale New Haven Hospital, New Haven, CT 06512, USA.
| | - Raphael Itzykson
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | | | - Haifa Al-Ali
- University Hospital of Halle, 06120 Halle, Germany.
| | - Jamile Shammo
- Rush University Medical Center, Chicago, IN 60612, USA.
| | | | | | - Jaime Wetzel
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Pellegrino Musto
- RCCS-CROB, Referral Cancer Center of Basilicata, 85028 Rionero in Vulture (Pz), Italy.
| | | | - Maria Joao Costa
- Centro Hospitalar Lisboa Norte Hospital Santa Maria, 1649-035 Lisbon, Portugal.
| | - Susana Esteves
- Instituto Português de Oncologia de Lisboa (IPOL), 1200-795 Lisbon, Portugal.
| | - Sonja Burgstaller
- Department of Internal Medicine IV, Hospital Wels-Grieskirchen, 4600 Wels, Austria.
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, 6020 Innsbruck, Austria.
| | - Eva M Autzinger
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Wilhelminenspital, 1160 Vienna, Austria.
| | - Alois Lang
- Internal Medicine, Hospital Feldkirch,6800 Feldkirch, Austria.
| | - Peter Krippl
- Department of Internal Medicine, Hospital Fürstenfeld, 8280 Fürstenfeld, Austria.
| | - Dietmar Geissler
- Department for Internal Medicine, Klinikum Klagenfurt am Wörthersee, 9020 Pörtschach am Wörthersee, Austria.
| | | | | | - Joan Bargay
- Hospital Son Llatzer, 07198 Palma de Mallorca, Spain.
| | | | - Ana Garrido
- Hospital de la Santa Creu i Sant Pau, 08026 Barcelona, Spain.
| | | | | | | | - Lionel Ades
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology and Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Pierre Fenaux
- Hopital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris Diderot University, 75010 Paris, France.
| | - Mikkael A Sekeres
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA.
| | - Richard Greil
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
| | - Lisa Pleyer
- 3rd Med. Department, Paracelsus Medical University, 5020 Salzburg, Austria.
- Salzburg Cancer Research Institute, 5020 Salzburg, Austria.
- Cancer Cluster Salzburg, 5020 Salzburg, Austria.
- Arbeitsgemeinschaft Medikamentöse Tumortherapie (AGMT), 5020 Salzburg, Austria.
| |
Collapse
|
56
|
Wolff F, Leisch M, Greil R, Risch A, Pleyer L. The double-edged sword of (re)expression of genes by hypomethylating agents: from viral mimicry to exploitation as priming agents for targeted immune checkpoint modulation. Cell Commun Signal 2017; 15:13. [PMID: 28359286 PMCID: PMC5374693 DOI: 10.1186/s12964-017-0168-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/21/2017] [Indexed: 12/20/2022] Open
Abstract
Hypomethylating agents (HMAs) have been widely used over the last decade, approved for use in myelodysplastic syndrome (MDS), chronic myelomonocytic leukemia (CMML) and acute myeloid leukemia (AML). The proposed central mechanism of action of HMAs, is the reversal of aberrant methylation in tumor cells, thus reactivating CpG-island promoters and leading to (re)expression of tumor suppressor genes. Recent investigations into the mode of action of azacitidine (AZA) and decitabine (DAC) have revealed new molecular mechanisms that impinge on tumor immunity via induction of an interferon response, through activation of endogenous retroviral elements (ERVs) that are normally epigenetically silenced. Although the global demethylation of DNA by HMAs can induce anti-tumor effects, it can also upregulate the expression of inhibitory immune checkpoint receptors and their ligands, resulting in secondary resistance to HMAs. Recent studies have, however, suggested that this could be exploited to prime or (re)sensitize tumors to immune checkpoint inhibitor therapies. In recent years, immune checkpoints have been targeted by novel therapies, with the aim of (re)activating the host immune system to specifically eliminate malignant cells. Antibodies blocking checkpoint receptors have been FDA-approved for some solid tumors and a plethora of clinical trials testing these and other checkpoint inhibitors are under way. This review will discuss AZA and DAC novel mechanisms of action resulting from the re-expression of pathologically hypermethylated promoters of gene sets that are related to interferon signaling, antigen presentation and inflammation. We also review new insights into the molecular mechanisms of action of transient, low-dose HMAs on various tumor types and discuss the potential of new treatment options and combinations.
Collapse
Affiliation(s)
- Florian Wolff
- Department of Molecular Biology, University of Salzburg, Salzburg, Austria
| | - Michael Leisch
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria
| | - Richard Greil
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.,Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Angela Risch
- Department of Molecular Biology, University of Salzburg, Salzburg, Austria.,Cancer Cluster Salzburg, Salzburg, Austria
| | - Lisa Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Müllner Hauptstraße 48, A-5020, Salzburg, Austria. .,Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria. .,Cancer Cluster Salzburg, Salzburg, Austria.
| |
Collapse
|
57
|
|
58
|
Qiu J, Peng B, Tang Y, Qian Y, Guo P, Li M, Luo J, Chen B, Tang H, Lu C, Cai M, Ke Z, He W, Zheng Y, Xie D, Li B, Yuan Y. CpG Methylation Signature Predicts Recurrence in Early-Stage Hepatocellular Carcinoma: Results From a Multicenter Study. J Clin Oncol 2017; 35:734-742. [PMID: 28068175 DOI: 10.1200/jco.2016.68.2153] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose Early-stage hepatocellular carcinoma (E-HCC) is being diagnosed increasingly, and in one half of diagnosed patients, recurrence will develop. Thus, it is urgent to identify recurrence-related markers. We investigated the effectiveness of CpG methylation in predicting recurrence for patients with E-HCCs. Patients and Methods In total, 576 patients with E-HCC from four independent centers were sorted by three phases. In the discovery phase, 66 tumor samples were analyzed using the Illumina Methylation 450k Beadchip. Two algorithms, Least Absolute Shrinkage and Selector Operation and Support Vector Machine-Recursive Feature Elimination, were used to select significant CpGs. In the training phase, penalized Cox regression was used to further narrow CpGs into 140 samples. In the validation phase, candidate CpGs were validated using an internal cohort (n = 141) and two external cohorts (n = 191 and n =104). Results After combining the 46 CpGs selected by the Least Absolute Shrinkage and Selector Operation and the Support Vector Machine-Recursive Feature Elimination algorithms, three CpGs corresponding to SCAN domain containing 3, Src homology 3-domain growth factor receptor-bound 2-like interacting protein 1, and peptidase inhibitor 3 were highlighted as candidate predictors in the training phase. On the basis of the three CpGs, a methylation signature for E-HCC (MSEH) was developed to classify patients into high- and low-risk recurrence groups in the training cohort ( P < .001). The performance of MSEH was validated in the internal cohort ( P < .001) and in the two external cohorts ( P < .001; P = .002). Furthermore, a nomogram comprising MSEH, tumor differentiation, cirrhosis, hepatitis B virus surface antigen, and antivirus therapy was generated to predict the 5-year recurrence-free survival in the training cohort, and it performed well in the three validation cohorts (concordance index: 0.725, 0.697, and 0.693, respectively). Conclusion MSEH, a three-CpG-based signature, is useful in predicting recurrence for patients with E-HCC.
Collapse
Affiliation(s)
- Jiliang Qiu
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Baogang Peng
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yunqiang Tang
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yeben Qian
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Pi Guo
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mengfeng Li
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Junhang Luo
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Bin Chen
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hui Tang
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Canliang Lu
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Muyan Cai
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zunfu Ke
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei He
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yun Zheng
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dan Xie
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Binkui Li
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yunfei Yuan
- Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, Sun Yat-sen University Cancer Center; Baogang Peng, Junhang Luo, Bin Chen, and Zunfu Ke, First Affiliated Hospital of Sun Yat-sen University; Pi Guo and Mengfeng Li, Sun Yat-sen University; Jiliang Qiu, Muyan Cai, Wei He, Yun Zheng, Dan Xie, Binkui Li, and Yunfei Yuan, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine; Jiliang Qiu, Yunqiang Tang, and Hui Tang, Guangzhou Medical University Cancer Center, Guangzhou; and Yeben Qian and Canliang Lu, First Affiliated Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
59
|
Almeida A, Fenaux P, List AF, Raza A, Platzbecker U, Santini V. Recent advances in the treatment of lower-risk non-del(5q) myelodysplastic syndromes (MDS). Leuk Res 2017; 52:50-57. [DOI: 10.1016/j.leukres.2016.11.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
|
60
|
Targeting the histone methyltransferase G9a activates imprinted genes and improves survival of a mouse model of Prader-Willi syndrome. Nat Med 2016; 23:213-222. [PMID: 28024084 DOI: 10.1038/nm.4257] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/29/2016] [Indexed: 12/13/2022]
Abstract
Prader-Willi syndrome (PWS) is an imprinting disorder caused by a deficiency of paternally expressed gene(s) in the 15q11-q13 chromosomal region. The regulation of imprinted gene expression in this region is coordinated by an imprinting center (PWS-IC). In individuals with PWS, genes responsible for PWS on the maternal chromosome are present, but repressed epigenetically, which provides an opportunity for the use of epigenetic therapy to restore expression from the maternal copies of PWS-associated genes. Through a high-content screen (HCS) of >9,000 small molecules, we discovered that UNC0638 and UNC0642-two selective inhibitors of euchromatic histone lysine N-methyltransferase-2 (EHMT2, also known as G9a)-activated the maternal (m) copy of candidate genes underlying PWS, including the SnoRNA cluster SNORD116, in cells from humans with PWS and also from a mouse model of PWS carrying a paternal (p) deletion from small nuclear ribonucleoprotein N (Snrpn (S)) to ubiquitin protein ligase E3A (Ube3a (U)) (mouse model referred to hereafter as m+/pΔS-U). Both UNC0642 and UNC0638 caused a selective reduction of the dimethylation of histone H3 lysine 9 (H3K9me2) at PWS-IC, without changing DNA methylation, when analyzed by bisulfite genomic sequencing. This indicates that histone modification is essential for the imprinting of candidate genes underlying PWS. UNC0642 displayed therapeutic effects in the PWS mouse model by improving the survival and the growth of m+/pΔS-U newborn pups. This study provides the first proof of principle for an epigenetics-based therapy for PWS.
Collapse
|
61
|
Santini V. Treatment of low-risk myelodysplastic syndromes. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:462-469. [PMID: 27913517 PMCID: PMC6142510 DOI: 10.1182/asheducation-2016.1.462] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The majority of myelodysplastic syndrome (MDS) patients belong to the International Prognostic Scoring System (IPSS) and IPSS-revised (IPSS-R) lower-risk categories. Their precise diagnostics and prognostic stratification is often a challenge, but may ensure the optimization of therapy. The availability of diverse treatment options has significantly improved the quality of life and survival of this group of patients. Anemia is the most relevant cytopenia in terms of frequency and symptoms in lower-risk MDS, and may be treated successfully with erythropoietic stimulating agents, provided a careful selection is performed on the basis of IPSS-R, endogenous erythropoietin levels, and transfusion independence. Doses and duration of therapy of erythropoietic-stimulating agents (ESAs) are critical to determine efficacy. In case a patient fails ESA treatment, the available options may include lenalidomide (approved for del5q positive cases), hypomethylating agents, and a rather large number of experimental agents, whose clinical trials should be offered to a larger number of MDS patients. The choice for second-line treatment must take into account biologic, cytogenetic, and molecular-identified characteristics of individual patients, as well as frailty and comorbidities. Other cytopenias are less frequently presenting as isolated. Specific therapy for thrombocytopenia has been proposed in experimental clinical trials with thrombomimetic agents that have shown good efficacy, but raised some safety concern. Although neutropenia is targeted symptomatically with growth factor supportive care, the immunosuppressive treatments are indicated mainly for pancytopenic, hypoplastic lower-risk MDS; they are not widely used because of their toxicity, despite the fact that they may induce responses. Finally, hematopoietic stem cell transplant is the curative option also for lower-risk MDS and timing should be carefully evaluated, balancing toxicity and the possibility of survival advantage. Finally, even when considered suitable for lower-risk MDS, transplant application is limited to the rarer fit and younger MDS patient.
Collapse
Affiliation(s)
- Valeria Santini
- SODc Hematology, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| |
Collapse
|
62
|
Chamseddine AN, Jabbour E, Kantarjian HM, Bohannan ZS, Garcia-Manero G. Unraveling Myelodysplastic Syndromes: Current Knowledge and Future Directions. Curr Oncol Rep 2016; 18:4. [PMID: 26700507 DOI: 10.1007/s11912-015-0489-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Myelodysplastic syndromes (MDS) affect more than 30,000 patients in the USA per year, most of whom are elderly, and these diseases are associated with dismal prognoses. The main features of MDS are ineffective hematopoiesis and aberrant myeloid differentiation. Furthermore, MDS are heterogeneous, both clinically and molecularly. This heterogeneity and the frequent occurrence of age-related comorbidities make the management of these diseases challenging. In fact, there have been no new drug approvals for MDS in the USA in the last 9 years, and few currently available investigational drugs are likely to be approved in the near future. Novel targeted treatment based on better understanding of the pathogenesis of MDS is needed to maximize patient outcomes. Here, we discuss new insights into diagnostic accuracy, prognostic assessment, pathogenic mechanisms, and effective treatments for MDS.
Collapse
Affiliation(s)
- Ali N Chamseddine
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77015, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77015, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77015, USA
| | - Zachary S Bohannan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77015, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77015, USA.
| |
Collapse
|
63
|
Canaani J, Nagler A. Established and emerging targeted therapies in the myelodysplastic syndromes. Expert Rev Hematol 2016; 9:997-1005. [PMID: 27615383 DOI: 10.1080/17474086.2016.1233054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Therapy for the myelodysplastic syndromes (MDS) is an evolving area of research which has made significant use of the increased understanding of the complex biology of these disorders. Novel agents targeting multiple pathogenic pathways are being actively tested in preclinical and clinical settings and hold the potential to be available to clinicians before long. AREAS COVERED Herein we provide an historical framework for understanding the current use of hypomethylating agents in MDS and discuss recent developments in the field of targeted therapy in MDS including data from published and ongoing clinical studies with oral hypomethylating agents, PI3/polo-like kinase inhibitors, TGF-β inhibitor/ligand traps, and immune checkpoint inhibitors. A comprehensive review of recent literature was undertaken using PubMed and Medline. Expert commentary: Management of MDS patients will evolve substantially in the near future with the incorporation of molecular data into patient stratification models and with the introduction of novel targeted agents.
Collapse
Affiliation(s)
- Jonathan Canaani
- a Hematology Division , Chaim Sheba Medical Center , Tel Hashomer , Israel
| | - Arnon Nagler
- a Hematology Division , Chaim Sheba Medical Center , Tel Hashomer , Israel
| |
Collapse
|
64
|
Sekeres MA. Long Day’s Journey Into Night for Lower-Risk Myelodysplastic Syndromes. J Clin Oncol 2016; 34:2956-7. [DOI: 10.1200/jco.2016.68.2492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
65
|
Zhang Z, Chang CK, He Q, Guo J, Tao Y, Wu LY, Xu F, Wu D, Zhou LY, Su JY, Song LX, Xiao C, Li X. Increased PD-1/STAT1 ratio may account for the survival benefit in decitabine therapy for lower risk myelodysplastic syndrome. Leuk Lymphoma 2016; 58:969-978. [DOI: 10.1080/10428194.2016.1219903] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
66
|
Salim O, Toptas T, Avsar E, Yucel OK, Ozturk E, Ferhanoglu B, Geduk A, Mehtap O, Tombak A, Tiftik EN, Deveci B, Kurtoglu E, Kara O, Atagunduz IK, Tuglular TF, Undar L. Azacitidine versus decitabine in patients with refractory anemia with excess blast—Results of multicenter study. Leuk Res 2016; 45:82-9. [DOI: 10.1016/j.leukres.2016.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 03/02/2016] [Accepted: 04/07/2016] [Indexed: 11/26/2022]
|
67
|
Thépot S, Ben Abdelali R, Chevret S, Renneville A, Beyne-Rauzy O, Prébet T, Park S, Stamatoullas A, Guerci-Bresler A, Cheze S, Tertian G, Choufi B, Legros L, Bastié JN, Delaunay J, Chaury MP, Sanhes L, Wattel E, Dreyfus F, Vey N, Chermat F, Preudhomme C, Fenaux P, Gardin C. A randomized phase II trial of azacitidine +/- epoetin-β in lower-risk myelodysplastic syndromes resistant to erythropoietic stimulating agents. Haematologica 2016; 101:918-25. [PMID: 27229713 DOI: 10.3324/haematol.2015.140988] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/26/2016] [Indexed: 11/09/2022] Open
Abstract
The efficacy of azacitidine in patients with anemia and with lower-risk myelodysplastic syndromes, if relapsing after or resistant to erythropoietic stimulating agents, and the benefit of combining these agents to azacitidine in this setting are not well known. We prospectively compared the outcomes of patients, all of them having the characteristics of this subset of lower-risk myelodysplastic syndrome, if randomly treated with azacitidine alone or azacitidine combined with epoetin-β. High-resolution cytogenetics and gene mutation analysis were performed at entry. The primary study endpoint was the achievement of red blood cell transfusion independence after six cycles. Ninety-eight patients were randomised (49 in each arm). Median age was 72 years. In an intention to treat analysis, transfusion independence was obtained after 6 cycles in 16.3% versus 14.3% of patients in the azacitidine and azacitidine plus epoetin-β arms, respectively (P=1.00). Overall erythroid response rate (minor and major responses according to IWG 2000 criteria) was 34.7% vs. 24.5% in the azacitidine and azacitidine plus epoetin-β arms, respectively (P=0.38). Mutations of the SF3B1 gene were the only ones associated with a significant erythroid response, 29/59 (49%) versus 6/27 (22%) in SF3B1 mutated and unmutated patients, respectively, P=0.02. Detection of at least one "epigenetic mutation" and of an abnormal single nucleotide polymorphism array profile were the only factors associated with significantly poorer overall survival by multivariate analysis. The transfusion independence rate observed with azacitidine in this lower-risk population, but resistant to erythropoietic stimulating agents, was lower than expected, with no observed benefit of added epoetin, (clinicaltrials.gov identifier: 01015352).
Collapse
Affiliation(s)
- Sylvain Thépot
- Service d'Hématologie Clinique, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (AP-HP), and Université Paris 13, Bobigny, France
| | | | - Sylvie Chevret
- Service de biostatistique et information médicale, Hôpital Saint-Louis, AP-HP and Université Paris 7, France
| | | | - Odile Beyne-Rauzy
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire, Toulouse, France
| | - Thomas Prébet
- Département d'Hématologie, Institut Paoli-Calmettes, Marseille, France
| | - Sophie Park
- Service d'Hématologie Clinique, Hôpital Cochin, AP-HP and Université Paris 5, France
| | | | | | - Stéphane Cheze
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire, Caen, France
| | - Gérard Tertian
- Service de médecine interne, Hôpital du kremlin-Bicetre, AP-HP and Université Paris, France
| | - Bachra Choufi
- Service d'Hématologie Clinique, Hôpital de Boulogne sur mer, France
| | - Laurence Legros
- Service d'Hématologie, Centre Hospitalier Universitaire, Nice, France
| | - Jean Noel Bastié
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire, Dijon, France
| | - Jacques Delaunay
- Service d'Hématologie, Centre Hospitalier Universitaire, Nantes, France
| | - Marie Pierre Chaury
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire, Limoges, France
| | - Laurence Sanhes
- Service d'Hématologie, Centre Hospitalier, Perpignan, France
| | - Eric Wattel
- Service d'Hématologie, Hôpital Universitaire Lyon Sud, Lyon, France
| | - Francois Dreyfus
- Service d'Hématologie Clinique, Hôpital Cochin, AP-HP and Université Paris 5, France
| | - Norbert Vey
- Département d'Hématologie, Institut Paoli-Calmettes, Marseille, France
| | - Fatiha Chermat
- Groupe francophone des Myélodysplasies, Hôpital Saint-Louis, AP-HP, France
| | | | - Pierre Fenaux
- Service d'Hématologie Clinique senior, Hôpital Saint-Louis, AP-HP and Université Paris 7, France
| | - Claude Gardin
- Service d'Hématologie Clinique, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (AP-HP), and Université Paris 13, Bobigny, France
| | | |
Collapse
|
68
|
Huang L, Garcia-Manero G, Jabbour E, Goswami M, Routbort MJ, Medeiros LJ, Jorgensen JL, Wang SA. Persistence of immunophenotypically aberrant CD34+ myeloid progenitors is frequent in bone marrow of patients with myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms treated with hypomethylating agents. J Clin Pathol 2016; 69:jclinpath-2016-203715. [PMID: 27083210 DOI: 10.1136/jclinpath-2016-203715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/22/2016] [Indexed: 12/31/2022]
Abstract
AIMS Hypomethylating agents (HMAs) exhibit clinical efficacy in patients with myelodysplastic syndromes (MDS) and myelodysplastic/myeloproliferative neoplasms (MDS/MPN). This study was performed to assess residual disease status by flow cytometry immunophenotyping (FCI) methods in patients with MDS or MDS/MPN treated with HMAs, and correlate the findings with clinical response. METHODS CD34+ myeloid precursors were assessed in 85 patients with MDS and MDS/MPN treated with HMAs using FCI methods. Morphological, cytogenetic and molecular assessments were performed to evaluate the responses. RESULTS After a median six cycles (3-19) of HMAs, 40 (47%) patients showed haematological improvement, 26 (63%) showed bone marrow (BM) and 20 (39%) cytogenetic response. However, CD34+ myeloid progenitors showed persistent immunophenotypic aberrancies in 72 (85%) patients, indeterminate in four (5%) and negative in nine (10%). Compared with pretreatment BM in a given patient, FCI abnormalities were reduced in 15 (20%) patients, similar in 37 (48%), increased in 15 (20%) and showed antigenic shift in nine (12%). Patients who achieved immunophenotypic improvement had a superior progression-free survival (p=0.031). In the subgroup of patients who underwent haematopoietic stem cell transplant (HSCT), 16/19 (84%) patients who had a pre-HSCT positive FCI study became normal. CONCLUSIONS These findings show the difficulty in eradicating neoplastic myeloid precursors by HMA therapy, thereby resulting in ultimate treatment failure in most patients. Achieving immunophenotypic improvement helps to identify patients who may benefit from continuous HMA treatment. HSCT provides a potential cure for these patients by replenishing BM with normal haematopoietic stem cells.
Collapse
Affiliation(s)
- Lanshan Huang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA Department of Pathology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maitrayee Goswami
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark J Routbort
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sa A Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
69
|
Peng J, Hasserjian RP, Tang G, Patel KP, Goswami M, Jabbour EJ, Garcia-Manero G, Medeiros LJ, Wang SA. Myelodysplastic syndromes following therapy with hypomethylating agents (HMAs): development of acute erythroleukemia may not influence assessment of treatment response. Leuk Lymphoma 2016; 57:812-9. [PMID: 26293512 DOI: 10.3109/10428194.2015.1079318] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study followed 28 patients with myelodysplastic syndromes (MDS) who showed a rise of bone marrow (BM) erythroids to ≥ 50% following three cycles (1-60) of hypomethylating agent (HMA) therapy. If BM blasts were calculated as a percentage of non-erythroids, 12 (42.9%) patients met the diagnostic criteria for acute erythroleukemia, erythroid/myeloid (AEL). However, none of the patients showed clonal cytogenetic evolution or new mutations. When compared to 47 de novo AEL patients, these 12 patients were less anemic and thrombocytopenic, had less complex karyotypes (p = 0.044) and showed a longer survival, either calculated from diagnosis (p < 0.001) or from the time of AEL (p = 0.005). These findings illustrate that ≥ 50% erythroids may appear in BM post-HMA therapy, likely a combination of reduction of BM granulocytes (p < 0.001) and promotion of normal or abnormal erythroid proliferation. Enumeration of blasts as a percentage of non-erythroid cells may lead to a diagnosis of AEL and mis-interpretation as disease progression.
Collapse
Affiliation(s)
- Jie Peng
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Robert P Hasserjian
- b Department of Pathology , Massachusetts General Hospital , Boston , MA , USA
| | - Guilin Tang
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Keyur P Patel
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Maitrayee Goswami
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Elias J Jabbour
- c Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Guillermo Garcia-Manero
- c Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - L Jeffrey Medeiros
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Sa A Wang
- a Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| |
Collapse
|
70
|
Li X, Shi J, Wang M, Nie N, Shao Y, Ge M, Huang J, Huang Z, Zhang J, Zheng Y. Cyclosporine Combined with Levamisole for Lower-Risk Myelodysplastic Syndromes. Acta Haematol 2015; 134:138-45. [PMID: 25925993 DOI: 10.1159/000370097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 11/25/2014] [Indexed: 11/19/2022]
Abstract
Clinical and experimental evidence suggests an immune-mediated pathophysiology in subjects with lower-risk myelodysplastic syndromes (MDS) in whom immunosuppressive therapy may be effective. The novel immunosuppressive strategy of cyclosporine A (CsA) alternately combined with levamisole (LMS; CsA + LMS regimen) can dramatically improve the response rate and survival in aplastic anemia from those of our previous study. Herein, we retrospectively analyzed the data of 89 lower-risk MDS patients who received the CsA + LMS regimen. A total of 63 patients (70.8%) achieved either complete remission or hematological improvement at 4 months. Overall, 51, 41 and 19 patients had erythroid, platelet and neutrophil responses, respectively. Following the CsA + LMS regimen, 6 patients progressed to more advanced MDS at a median interval of 5 months (range, 3-42 months). The estimated 24-month progression-free survival was 82.2% (95% CI, 72.84-91.56) for all patients. Within the median follow-up of 18.5 months (range, 7.0-61.0), 6 patients died. In conclusion, the CsA + LMS regimen alleviated cytopenias and improved survival and freedom from evolution, suggesting that it could be reserved as an alternative choice for lower-risk MDS.
Collapse
Affiliation(s)
- Xingxin Li
- Severe Aplastic Anemia Studying Program, State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, PR China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
71
|
Endo S, Amano M, Nishimura N, Ueno N, Ueno S, Yuki H, Fujiwara S, Wada N, Hirata S, Hata H, Mitsuya H, Okuno Y. Immunomodulatory drugs act as inhibitors of DNA methyltransferases and induce PU.1 up-regulation in myeloma cells. Biochem Biophys Res Commun 2015; 469:236-42. [PMID: 26657848 DOI: 10.1016/j.bbrc.2015.11.116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/25/2015] [Indexed: 11/27/2022]
Abstract
Immunomodulatory drugs (IMiDs) such as thalidomide, lenalidomide, and pomalidomide are efficacious in the treatment of multiple myeloma and significantly prolong their survival. However, the mechanisms of such effects of IMiDs have not been fully elucidated. Recently, cereblon has been identified as a target binding protein of thalidomide. Lenalidomide-resistant myeloma cell lines often lose the expression of cereblon, suggesting that IMiDs act as an anti-myeloma agent through interacting with cereblon. Cereblon binds to damaged DNA-binding protein and functions as a ubiquitin ligase, inducing degradation of IKZF1 and IKZF3 that are essential transcription factors for B and T cell development. Degradation of both IKZF1 and IKZF3 reportedly suppresses myeloma cell growth. Here, we found that IMiDs act as inhibitors of DNA methyltransferases (DMNTs). We previously reported that PU.1, which is an ETS family transcription factor and essential for myeloid and lymphoid development, functions as a tumor suppressor in myeloma cells. PU.1 induces growth arrest and apoptosis of myeloma cell lines. In this study, we found that low-dose lenalidomide and pomalidomide up-regulate PU.1 expression through inducing demethylation of the PU.1 promoter. In addition, IMiDs inhibited DNMT1, DNMT3a, and DNMT3b activities in vitro. Furthermore, lenalidomide and pomalidomide decreased the methylation status of the whole genome in myeloma cells. Collectively, IMiDs exert demethylation activity through inhibiting DNMT1, 3a, and 3b, and up-regulating PU.1 expression, which may be one of the mechanisms of the anti-myeloma activity of IMiDs.
Collapse
Affiliation(s)
- Shinya Endo
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Masayuki Amano
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Nao Nishimura
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Niina Ueno
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Shikiko Ueno
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiromichi Yuki
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Shiho Fujiwara
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Naoko Wada
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Shinya Hirata
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiroyuki Hata
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiroaki Mitsuya
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Yutaka Okuno
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| |
Collapse
|
72
|
Garcia-Manero G, Gore SD, Kambhampati S, Scott B, Tefferi A, Cogle CR, Edenfield WJ, Hetzer J, Kumar K, Laille E, Shi T, MacBeth KJ, Skikne B. Efficacy and safety of extended dosing schedules of CC-486 (oral azacitidine) in patients with lower-risk myelodysplastic syndromes. Leukemia 2015; 30:889-96. [PMID: 26442612 PMCID: PMC4832070 DOI: 10.1038/leu.2015.265] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/02/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022]
Abstract
CC-486, the oral formulation of azacitidine (AZA), is an epigenetic modifier and DNA methyltransferase inhibitor in clinical development for treatment of hematologic malignancies. CC-486 administered for 7 days per 28-day treatment cycle was evaluated in a phase 1 dose-finding study. AZA has a short plasma half-life and DNA incorporation is S-phase-restricted; extending CC-486 exposure may increase the number of AZA-affected diseased target cells and maximize therapeutic effects. Patients with lower-risk myelodysplastic syndromes (MDS) received 300 mg CC-486 once daily for 14 days (n=28) or 21 days (n=27) of repeated 28-day cycles. Median patient age was 72 years (range 31–87) and 75% of patients had International Prognostic Scoring System Intermediate-1 risk MDS. Median number of CC-486 treatment cycles was 7 (range 2–24) for the 14-day dosing schedule and 6 (1–24) for the 21-day schedule. Overall response (complete or partial remission, red blood cell (RBC) or platelet transfusion independence (TI), or hematologic improvement) (International Working Group 2006) was attained by 36% of patients receiving 14-day dosing and 41% receiving 21-day dosing. RBC TI rates were similar with both dosing schedules (31% and 38%, respectively). CC-486 was generally well-tolerated. Extended dosing schedules of oral CC-486 may provide effective long-term treatment for patients with lower-risk MDS.
Collapse
Affiliation(s)
- G Garcia-Manero
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S D Gore
- Yale Cancer Center, New Haven, CT, USA
| | - S Kambhampati
- Division of Hematology/Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - B Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - A Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - C R Cogle
- Medicine/Hematology & Oncology, University of Florida, Gainesville, FL, USA
| | - W J Edenfield
- Cancer Centers of The Carolinas, Greenville, SC, USA
| | - J Hetzer
- Celgene Corporation, Summit, NJ, USA
| | - K Kumar
- Celgene Corporation, Summit, NJ, USA
| | - E Laille
- Celgene Corporation, Summit, NJ, USA
| | - T Shi
- Celgene Corporation, Summit, NJ, USA
| | | | - B Skikne
- Celgene Corporation, Summit, NJ, USA
| |
Collapse
|
73
|
Falantes JF, Garcia-Manero G. Does the concept of lower-risk myelodysplastic syndrome need to be revisited? Leuk Res 2015. [DOI: 10.1016/j.leukres.2015.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
74
|
Garcia-Manero G. Myelodysplastic syndromes: 2015 Update on diagnosis, risk-stratification and management. Am J Hematol 2015; 90:831-41. [PMID: 26294090 DOI: 10.1002/ajh.24102] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 02/03/2023]
Abstract
DISEASE OVERVIEW The myelodysplastic syndromes (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older males and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry, or molecular genetics is complementary but not diagnostic. Risk-stratification: Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow, and cytogenetic characteristics. The most commonly used system still is probably the International Prognostic Scoring System (IPSS). IPSS is being replaced by the new revised score IPSS-R. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts, and more recently cytogenetic and mutational profiles. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy, and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia, and a chromosome 5 alteration. 5-Azacitidine and decitabine have activity in higher risk MDS. 5-Azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. Management of progressive or refractory disease: At the present time there are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include participation in a clinical trial or cytarabine based therapy and stem cell transplantation.
Collapse
|
75
|
Abou Zahr A, Saad Aldin E, Barbarotta L, Podoltsev N, Zeidan AM. The clinical use of DNA methyltransferase inhibitors in myelodysplastic syndromes. Expert Rev Anticancer Ther 2015; 15:1019-36. [DOI: 10.1586/14737140.2015.1061936] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
76
|
Greve G, Schiffmann I, Lübbert M. Epigenetic priming of non-small cell lung cancer cell lines to the antiproliferative and differentiating effects of all-trans retinoic acid. J Cancer Res Clin Oncol 2015; 141:2171-80. [DOI: 10.1007/s00432-015-1987-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/09/2015] [Indexed: 12/27/2022]
|
77
|
Reikvam H, Hoang TTV, Bruserud Ø. Emerging therapeutic targets in human acute myeloid leukemia (part 2) – bromodomain inhibition should be considered as a possible strategy for various patient subsets. Expert Rev Hematol 2015; 8:315-27. [DOI: 10.1586/17474086.2015.1036025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
78
|
Saunthararajah Y, Sekeres M, Advani A, Mahfouz R, Durkin L, Radivoyevitch T, Englehaupt R, Juersivich J, Cooper K, Husseinzadeh H, Przychodzen B, Rump M, Hobson S, Earl M, Sobecks R, Dean R, Reu F, Tiu R, Hamilton B, Copelan E, Lichtin A, Hsi E, Kalaycio M, Maciejewski J. Evaluation of noncytotoxic DNMT1-depleting therapy in patients with myelodysplastic syndromes. J Clin Invest 2015; 125:1043-55. [PMID: 25621498 PMCID: PMC4362268 DOI: 10.1172/jci78789] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/15/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Mutational inactivation in cancer of key apoptotic pathway components, such as TP53/p53, undermines cytotoxic therapies that aim to increase apoptosis. Accordingly, TP53 mutations are reproducibly associated with poor treatment outcomes. Moreover, cytotoxic treatments destroy normal stem cells with intact p53 systems, a problem especially for myeloid neoplasms, as these cells reverse the low blood counts that cause morbidity and death. Preclinical studies suggest that noncytotoxic concentrations of the DNA methyltransferase 1 (DNMT1) inhibitor decitabine produce p53-independent cell-cycle exits by reversing aberrant epigenetic repression of proliferation-terminating (MYC-antagonizing) differentiation genes in cancer cells. METHODS In this clinical trial, patients with myelodysplastic syndrome (n=25) received reduced decitabine dosages (0.1-0.2 mg/kg/day compared with the FDA-approved 20-45 mg/m2/day dosage, a 75%-90% reduction) to avoid cytotoxicity. These well-tolerated doses were frequently administered 1-3 days per week, instead of pulse cycled for 3 to 5 days over a 4- to 6-week period, to increase the probability that cancer S-phase entries would coincide with drug exposure, which is required for S-phase-dependent DNMT1 depletion. RESULTS The median subject age was 73 years (range, 46-85 years), 9 subjects had relapsed disease or were refractory to 5-azacytidine and/or lenalidomide, and 3 had received intensive chemoradiation to treat other cancers. Adverse events were related to neutropenia present at baseline: neutropenic fever (13 of 25 subjects) and septic death (1 of 25 subjects). Blood count improvements meeting the International Working Group criteria for response occurred in 11 of 25 (44%) subjects and were highly durable. Treatment-induced freedom from transfusion lasted a median of 1,025 days (range, 186-1,152 days; 3 ongoing), and 20% of subjects were treated for more than 3 years. Mutations and/or deletions of key apoptosis genes were frequent (present in 55% of responders and in 36% of nonresponders). Noncytotoxic DNMT1 depletion was confirmed by serial BM γ-H2AX (DNA repair/damage marker) and DNMT1 analyses. MYC master oncoprotein levels were markedly decreased. CONCLUSION Decitabine regimens can be redesigned to minimize cytotoxicity and increase exposure time for DNMT1 depletion, to safely and effectively circumvent mutational apoptotic defects. TRIAL REGISTRATION Clinicaltrials.gov NCT01165996. FUNDING NIH (R01CA138858, CA043703); Department of Defense (PR081404); Clinical and Translational Science Award (CTSA) (UL1RR024989); and the Leukemia and Lymphoma Society (Translational Research Program).
Collapse
Affiliation(s)
- Yogen Saunthararajah
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | - Mikkael Sekeres
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | | | - Reda Mahfouz
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | - Lisa Durkin
- Department of Clinical Pathology, Tomsich Pathology Institute, and
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | | - Holleh Husseinzadeh
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | | | | | | | - Marc Earl
- Department of Hematology and Oncology
| | | | | | - Frederic Reu
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | - Ramon Tiu
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | - Betty Hamilton
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| | - Edward Copelan
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | | | - Eric Hsi
- Department of Clinical Pathology, Tomsich Pathology Institute, and
| | | | - Jaroslaw Maciejewski
- Department of Hematology and Oncology
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute
| |
Collapse
|
79
|
Affiliation(s)
- Edward L Korn
- Biometric Research Branch, National Cancer Institute, Bethesda, MD, USA
| | - Boris Freidlin
- Biometric Research Branch, National Cancer Institute, Bethesda, MD, USA
| |
Collapse
|
80
|
Abstract
Randomization is firmly established as a cornerstone of clinical trial methodology. Yet, the ethics of randomization continues to generate controversy. The default, and most efficient, allocation scheme randomizes patients equally (1:1) across all arms of study. However, many randomized trials are using outcome-adaptive allocation schemes, which dynamically adjust the allocation ratio in favor of the better performing treatment arm. Advocates of outcome-adaptive allocation contend that it better accommodates clinical equipoise and promotes informed consent, since such trials limit patient-subject exposure to sub-optimal care. In this essay, we argue that this purported ethical advantage of outcome-adaptive allocation does not stand up to careful scrutiny in the setting of two-armed studies and/or early-phase research.
Collapse
Affiliation(s)
- Spencer Phillips Hey
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
| |
Collapse
|
81
|
Abstract
Abstract
The myelodysplastic syndromes (MDS) are the most commonly diagnosed myeloid malignancy, with >15 000 new cases identified in the United States yearly. Prognostic scoring systems supplant a formal staging approach and, in general, divide patients into those with lower-risk and those with higher-risk MDS. Although treatment goals for patients with lower-risk disease focus on minimizing transfusions and optimizing quality of life, in higher-risk MDS, the goal is to delay transformation to acute leukemia and to prolong survival. In lower-risk patients, isolated cytopenias are treated with erythropoiesis-stimulating agents or growth factors such as thrombopoietin mimetics. For patients with the del(5q) cytogenetic abnormality or those who fail these initial approaches, lenalidomide may be tried, as can experimental agents. Lower-risk patients with multiple cytopenias may be treated with immunosuppressive drugs or low-dose hypomethylating agents. For patients with higher-risk disease, hypomethylating agents are the preferred initial treatment approach, with evaluation for hematopoietic cell transplantation at diagnosis. Several novel agents are being developed for MDS patients who have failed hypomethylating drugs.
Collapse
|
82
|
Xie M, Jiang Q, Xie Y. Comparison between decitabine and azacitidine for the treatment of myelodysplastic syndrome: a meta-analysis with 1,392 participants. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 15:22-8. [PMID: 25042977 DOI: 10.1016/j.clml.2014.04.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 04/01/2014] [Accepted: 04/03/2014] [Indexed: 11/25/2022]
Abstract
The hypomethylating agents decitabine and azacitidine have been found to improve the outcome of patients with myelodysplastic syndrome (MDS); however, the clinical choice between them is controversial. Therefore, this meta-analysis was performed to compare the efficacy, toxicity, and survival advantage of decitabine and azacitidine in patients with MDS. Eleven trials with a total of 1392 patients with MDS (decitabine, n = 768; azacitidine, n = 624) were included for analysis. The pooled estimates of partial response, hematologic improvement, and overall response rates for azacitidine were significantly higher than for decitabine. There were no differences between these 2 drugs regarding complete response, red blood cell transfusion-independent rates, and grade 3 or 4 hematologic toxicity. When compared with best supportive care, azacitidine significantly improved overall survival (hazard ratio [HR], 0.69; 95% CI, 0.54-0.87) and time to acute myeloid leukemia transformation (HR, 0.51; 95% CI, 0.35-0.74). But these benefits were not found with decitabine. Among patients with higher risk (International Prognostic Scoring System value of 3) or older than 75 years, treatment with azacitidine was a favorable factor, whereas decitabine showed no advantage. Therefore, with higher overall response rates and better survival benefits, azacitidine is recommended as the first-line hypomethylating agent for MDS, especially in elderly patients or those with high risk.
Collapse
Affiliation(s)
- Mixue Xie
- Department of Hematology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Qi Jiang
- Department of Cancer Biotherapy, Third Affiliated Hospital of the People's Liberation Army Second Military Medical University, Shanghai, China; Gene-Viral Therapy Laboratory, Third Affiliated Hospital of the People's Liberation Army Second Military Medical University, Shanghai, China
| | - Yanhui Xie
- Department of Hematology, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
| |
Collapse
|
83
|
Li X, Song Q, Chen Y, Chang C, Wu D, Wu L, Su J, Zhang X, Zhou L, Song L, Zhang Z, Xu F, Hou M. Decitabine of reduced dosage in Chinese patients with myelodysplastic syndrome: a retrospective analysis. PLoS One 2014; 9:e95473. [PMID: 24748149 PMCID: PMC3991661 DOI: 10.1371/journal.pone.0095473] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 03/27/2014] [Indexed: 11/27/2022] Open
Abstract
Decitabine has been approved for the treatment of all subtypes of myelodysplastic syndrome (MDS). However, the optimal regimen for decitabine treatment is not well established. In this study, an observational, retrospective and multi-center analysis was performed to explore the decitabine schedule for the treatment of MDS. A total of 79 patients received reduced dosage decitabine treatment (15 mg/M2/day intravenously for five consecutive days every four weeks). Fifty-three out of the 79 patients were defined as intermediate-2/high risk by international prognostic scoring system (IPSS) risk category. 67.1% of MDS patients achieved treatment response including complete response (CR) (n = 23), Partial response (n = 1), marrow CR (mCR) with hematological improvement (HI) (n = 11), mCR without HI (n = 11) and HI alone (n = 7) with a median of 4 courses (range 1–11). The median overall survival (OS) was 18.0 months. The median OS was 22.0, 17.0 and 12.0 months in the patients with CR, those with other response, and those without response, respectively. In addition, this regimen contributed to zero therapy-related death and punctual course delivery, although III or IV grade of cytopenia was frequently observed. In conclusion, the 15 mg/M2/d×5 day decitabine regimen was effective and safe for Chinese MDS patients with IPSS score of 0.5 or higher.
Collapse
Affiliation(s)
- Xiao Li
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
- * E-mail:
| | - Qiang Song
- Department of Hematology, Qilu Hospital affiliated with Shandong University, Jinan, China
| | - Yu Chen
- Department of Hematology, Ruijin Hospital affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chunkang Chang
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Dong Wu
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Lingyun Wu
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Jiying Su
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Xi Zhang
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Liyu Zhou
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Luxi Song
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Zheng Zhang
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Feng Xu
- Department of Hematology, the Sixth People’s Hospital affiliated with Shanghai Jiaotong University, Shanghai, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital affiliated with Shandong University, Jinan, China
| |
Collapse
|
84
|
Abstract
The field of epigenetics has exploded in the last two decades, with incredible advances in recent years driven by high-throughput sequencing studies. Cancer cells frequently exhibit marked changes in DNA methylation and histone modification during tumorigenesis and tumor progression. These changes in the cancer epigenome are thought to be important in initiating and maintaining malignancy, and pharmaceutical approaches targeting epigenome-modifying enzymes are an attractive therapeutic strategy. Early successes have been made with DNA-demethylating drugs in hematologic malignancies, and efforts are underway to target additional epigenetic regulators and a broader array of tumor types. The Reviews in this issue of the JCI highlight ongoing efforts in this burgeoning field to translate our understanding of the cancer epigenome into successful interventional strategies in the clinic.
Collapse
|
85
|
Garcia-Manero G. Reply to T. Radivoyevitch et al. J Clin Oncol 2014; 32:61. [DOI: 10.1200/jco.2013.53.1038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
86
|
Radivoyevitch T, Saunthararajah Y. Sex difference in myelodysplastic syndrome survival and balance in randomized clinical trials. J Clin Oncol 2014; 32:60-1. [PMID: 24248691 DOI: 10.1200/jco.2013.52.5980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
87
|
Garcia-Manero G. Myelodysplastic syndromes: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:97-108. [PMID: 24464505 DOI: 10.1002/ajh.23642] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Indexed: 02/03/2023]
Abstract
DISEASE OVERVIEW The myelodysplastic (MDS) are a very heterogeneous group of myeloid disorders characterized by peripheral blood cytopenias and increased risk of transformation to acute myelogenous leukemia (AML). MDS occurs more frequently in older male and in individuals with prior exposure to cytotoxic therapy. DIAGNOSIS Diagnosis of MDS is based on morphological evidence of dysplasia upon visual examination of a bone marrow aspirate and biopsy. Information obtained from additional studies such as karyotype, flow cytometry or molecular genetics is complementary but not diagnostic. RISK-STRATIFICATION: Prognosis of patients with MDS can be calculated using a number of scoring systems. In general, all these scoring systems include analysis of peripheral cytopenias, percentage of blasts in the bone marrow and cytogenetic characteristics. The most commonly used system is the International Prognostic Scoring System (IPSS). IPSS is likely to be replaced by a new revised score (IPSS-R) and by the incorporation of new molecular markers recently described. RISK-ADAPTED THERAPY Therapy is selected based on risk, transfusion needs, percent of bone marrow blasts and more recently cytogenetic profile. Goals of therapy are different in lower risk patients than in higher risk. In lower risk, the goal is to decrease transfusion needs and transformation to higher risk disease or AML, as well as to improve survival. In higher risk, the goal is to prolong survival. Current available therapies include growth factor support, lenalidomide, hypomethylating agents, intensive chemotherapy, and allogeneic stem cell transplantation. The use of lenalidomide has significant clinical activity in patients with lower risk disease, anemia, and a chromosome 5 alteration. 5-Azacitidine and decitabine have activity in higher risk MDS. 5-Azacitidine has been shown to improve survival in higher risk MDS. A number of new molecular lesions have been described in MDS that may serve as new therapeutic targets or aid in the selection of currently available agents. Additional supportive care measures may include the use of prophylactic antibiotics and iron chelation. MANAGEMENT OF PROGRESSIVE OR REFRACTORY DISEASE There are no approved interventions for patients with progressive or refractory disease particularly after hypomethylating based therapy. Options include cytarabine based therapy, transplantation and participation on a clinical trial.
Collapse
|
88
|
Abstract
Higher-risk myelodysplastic syndromes (MDS) are defined by patients who fall into higher-risk group categories in the original or revised International Prognostic Scoring System. Survival for these patients is dismal, and treatment should be initiated rapidly. Standard therapies include the hypomethylating agents azacitidine and decitabine, which should be administered for a minimum of 6 cycles, and continued for as long as a patient is responding. Once a drug fails in one of these patients, further treatment options are limited, median survival is <6 months, and consideration should be given to clinical trials. Higher-risk eligible patients should be offered consultation to discuss hematopoietic stem cell transplantation close to the time of diagnosis, depending on patient goals of therapy, with consideration given to proceeding to transplantation soon after an optimal donor is located. In the interim period before transplantation, hypomethylating agent therapy, induction chemotherapy, or enrollment in a clinical trial should be considered to prevent disease progression, although the optimal pretransplantation therapy is unknown.
Collapse
|
89
|
Expression of PD-L1, PD-L2, PD-1 and CTLA4 in myelodysplastic syndromes is enhanced by treatment with hypomethylating agents. Leukemia 2013; 28:1280-8. [PMID: 24270737 PMCID: PMC4032802 DOI: 10.1038/leu.2013.355] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 10/31/2013] [Indexed: 12/20/2022]
Abstract
Blockade of immune checkpoints is emerging as a new form of anticancer therapy. We studied the expression of programmed death ligand 1 (PD-L1), PD-L2, programmed death 1 (PD-1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA4) mRNA in CD34+ cells from myelodysplastic syndrome (MDS), chronic myelomonocytic leukemia (CMML) and acute myeloid leukemia (AML) patients (N=124). Aberrant upregulation (⩾2-fold) was observed in 34, 14, 15 and 8% of the patients. Increased expression of these four genes was also observed in peripheral blood mononuclear cells (PBMNCs) (N=61). The relative expression of PD-L1 from PBMNC was significantly higher in MDS (P=0.018) and CMML (P=0.0128) compared with AML. By immunohistochemical analysis, PD-L1 protein expression was observed in MDS CD34+ cells, whereas stroma/non-blast cellular compartment was positive for PD-1. In a cohort of patients treated with epigenetic therapy, PD-L1, PD-L2, PD-1 and CTLA4 expression was upregulated. Patients resistant to therapy had relative higher increments in gene expression compared with patients who achieved response. Treatment of leukemia cells with decitabine resulted in a dose-dependent upregulation of above genes. Exposure to decitabine resulted in partial demethylation of PD-1 in leukemia cell lines and human samples. This study suggests that PD-1 signaling may be involved in MDS pathogenesis and resistance mechanisms to hypomethylating agents. Blockade of this pathway can be a potential therapy in MDS and AML.
Collapse
|