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Abstract
The cell cycle of eukaryotic cells varies greatly from species to species and tissue to tissue. Since an erroneous control of the cell cycle can have disastrous consequences for cellular life, there are genetically programmed signals, so-called cell cycle checkpoints, which ensure that all events of each stage are completed before beginning the next phase. Among the numerous molecules involved in this process, the most important are the cyclin-dependent kinases (CDKs), proteins that are activated only when bound to cyclins (regulatory proteins with fluctuating concentrations). In general, more CDKs are overexpressed in cancer cells than in normal cells, which explains why cancer cells divide uncontrollably. Succeeding in modulating CDK activity with pharmacological agents could result in decreasing the abnormal proliferation rate of cancer cells. This review offers an overview of CDK-cyclin complexes in relation to different cell cycle phases, an analysis of CDK activation and inhibition of molecular mechanisms, and an extensive report, including clinical trials, regarding four new drugs acting as CDK modulators: alvocidib, P276-00, SNS-032 and seliciclib.
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Abstract
The cell cycle of eukaryotic cells varies greatly from species to species and tissue to tissue. Since an erroneous control of the cell cycle can have disastrous consequences for cellular life, there are genetically programmed signals, so-called cell cycle checkpoints, which ensure that all events of each stage are completed before beginning the next phase. Among the numerous molecules involved in this process, the most important are the cyclin-dependent kinases (CDKs), proteins that are activated only when bound to cyclins (regulatory proteins with fluctuating concentrations). In general, more CDKs are overexpressed in cancer cells than in normal cells, which explains why cancer cells divide uncontrollably. Succeeding in modulating CDK activity with pharmacological agents could result in decreasing the abnormal proliferation rate of cancer cells. This review offers an overview of CDK-cyclin complexes in relation to different cell cycle phases, an analysis of CDK activation and inhibition of molecular mechanisms, and an extensive report, including clinical trials, regarding four new drugs acting as CDK modulators: alvocidib, P276-00, SNS-032 and seliciclib.
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103
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Cosimo E, McCaig AM, Carter-Brzezinski LJM, Wheadon H, Leach MT, Le Ster K, Berthou C, Durieu E, Oumata N, Galons H, Meijer L, Michie AM. Inhibition of NF-κB-mediated signaling by the cyclin-dependent kinase inhibitor CR8 overcomes prosurvival stimuli to induce apoptosis in chronic lymphocytic leukemia cells. Clin Cancer Res 2013; 19:2393-405. [PMID: 23532892 DOI: 10.1158/1078-0432.ccr-12-2170] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Chronic lymphocytic leukemia (CLL) is currently incurable with standard chemotherapeutic agents, highlighting the need for novel therapies. Overcoming proliferative and cytoprotective signals generated within the microenvironment of lymphoid organs is essential for limiting CLL progression and ultimately developing a cure. EXPERIMENTAL DESIGN We assessed the potency of cyclin-dependent kinase (CDK) inhibitor CR8, a roscovitine analog, to induce apoptosis in primary CLL from distinct prognostic subsets using flow cytometry-based assays. CLL cells were cultured in in vitro prosurvival and proproliferative conditions to mimic microenvironmental signals in the lymphoid organs, to elucidate the mechanism of action of CR8 in quiescent and proliferating CLL cells using flow cytometry, Western blotting, and quantitative real-time PCR. RESULTS CR8 was 100-fold more potent at inducing apoptosis in primary CLL cells than roscovitine, both in isolated culture and stromal-coculture conditions. Importantly, CR8 induced apoptosis in CD40-ligated CLL cells and preferentially targeted actively proliferating cells within these cultures. CR8 treatment induced downregulation of the antiapoptotic proteins Mcl-1 and XIAP, through inhibition of RNA polymerase II, and inhibition of NF-κB signaling at the transcriptional level and through inhibition of the inhibitor of IκB kinase (IKK) complex, resulting in stabilization of IκBα expression. CONCLUSIONS CR8 is a potent CDK inhibitor that subverts pivotal prosurvival and proproliferative signals present in the tumor microenvironment of CLL patient lymphoid organs. Our data support the clinical development of selective CDK inhibitors as novel therapies for CLL.
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Affiliation(s)
- Emilio Cosimo
- Institute of Cancer Sciences, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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104
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Holkova B, Supko JG, Ames MM, Reid JM, Shapiro GI, Perkins EB, Ramakrishnan V, Tombes MB, Honeycutt C, McGovern RM, Kmieciak M, Shrader E, Wellons MD, Sankala H, Doyle A, Wright J, Roberts JD, Grant S. A phase I trial of vorinostat and alvocidib in patients with relapsed, refractory, or poor prognosis acute leukemia, or refractory anemia with excess blasts-2. Clin Cancer Res 2013; 19:1873-83. [PMID: 23515411 DOI: 10.1158/1078-0432.ccr-12-2926] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE This phase I study was conducted to identify the maximum-tolerated dose (MTD) of alvocidib when combined with vorinostat in patients with relapsed, refractory, or poor prognosis acute leukemia, or refractory anemia with excess blasts-2. Secondary objectives included investigating the pharmacokinetic and pharmacodynamic effects of the combination. EXPERIMENTAL DESIGN Patients received vorinostat (200 mg orally, three times a day, for 14 days) on a 21-day cycle, combined with 2 different alvocidib administration schedules: a 1-hour intravenous infusion, daily × 5; or a 30-minute loading infusion followed by a 4-hour maintenance infusion, weekly × 2. The alvocidib dose was escalated using a standard 3+3 design. RESULTS Twenty-eight patients were enrolled and treated. The alvocidib MTD was 20 mg/m(2) (30-minute loading infusion) followed by 20 mg/m(2) (4-hour maintenance infusion) on days one and eight, in combination with vorinostat. The most frequently encountered toxicities were cytopenias, fatigue, hyperglycemia, hypokalemia, hypophosphatemia, and QT prolongation. Dose-limiting toxicities (DLT) were cardiac arrhythmia-atrial fibrillation and QT prolongation. No objective responses were achieved although 13 of 26 evaluable patients exhibited stable disease. Alvocidib seemed to alter vorinostat pharmacokinetics, whereas alvocidib pharmacokinetics were unaffected by vorinostat. Ex vivo exposure of leukemia cells to plasma obtained from patients after alvocidib treatment blocked vorinostat-mediated p21(CIP1) induction and downregulated Mcl-1 and p-RNA Pol II for some specimens, although parallel in vivo bone marrow responses were infrequent. CONCLUSIONS Alvocidib combined with vorinostat is well tolerated. Although disease stabilization occurred in some heavily pretreated patients, objective responses were not obtained with these schedules.
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Affiliation(s)
- Beata Holkova
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA.
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105
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Hole A, Baumli S, Shao H, Shi S, Huang S, Pepper C, Fischer P, Wang S, Endicott JA, Noble ME. Comparative structural and functional studies of 4-(thiazol-5-yl)-2-(phenylamino)pyrimidine-5-carbonitrile CDK9 inhibitors suggest the basis for isotype selectivity. J Med Chem 2013; 56:660-70. [PMID: 23252711 PMCID: PMC3579457 DOI: 10.1021/jm301495v] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Indexed: 01/08/2023]
Abstract
Cyclin-dependent kinase 9/cyclin T, the protein kinase heterodimer that constitutes positive transcription elongation factor b, is a well-validated target for treatment of several diseases, including cancer and cardiac hypertrophy. In order to aid inhibitor design and rationalize the basis for CDK9 selectivity, we have studied the CDK-binding properties of six different members of a 4-(thiazol-5-yl)-2-(phenylamino)pyrimidine-5-carbonitrile series that bind to both CDK9/cyclin T and CDK2/cyclin A. We find that for a given CDK, the melting temperature of a CDK/cyclin/inhibitor complex correlates well with inhibitor potency, suggesting that differential scanning fluorimetry (DSF) is a useful orthogonal measure of inhibitory activity for this series. We have used DSF to demonstrate that the binding of these compounds is independent of the presence or absence of the C-terminal tail region of CDK9, unlike the binding of the CDK9-selective inhibitor 5,6-dichlorobenzimidazone-1-β-d-ribofuranoside (DRB). Finally, on the basis of 11 cocrystal structures bound to CDK9/cyclin T or CDK2/cyclin A, we conclude that selective inhibition of CDK9/cyclin T by members of the 4-(thiazol-5-yl)-2-(phenylamino)pyrimidine-5-carbonitrile series results from the relative malleability of the CDK9 active site rather than from the formation of specific polar contacts.
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Affiliation(s)
- Alison
J. Hole
- Department
of Biochemistry, University of Oxford,
South Parks Road, Oxford OX1
3QU, U.K
| | - Sonja Baumli
- Department
of Biochemistry, University of Oxford,
South Parks Road, Oxford OX1
3QU, U.K
| | - Hao Shao
- School of Pharmacy
and Centre
for Biomolecular Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, U.K
| | - Shenhua Shi
- School of Pharmacy
and Centre
for Biomolecular Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, U.K
| | - Shiliang Huang
- School of Pharmacy
and Centre
for Biomolecular Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, U.K
| | - Chris Pepper
- Institute of Cancer and Genetics,
School of Medicine, Cardiff University,
Heath Park, Cardiff CF14 4XN, U.K
| | - Peter
M. Fischer
- School of Pharmacy
and Centre
for Biomolecular Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, U.K
| | - Shudong Wang
- School of Pharmacy
and Centre
for Biomolecular Sciences, University of Nottingham, University Park, Nottingham NG7 2RD, U.K
- School of Pharmacy and Medical
Sciences, University of South Australia, Adelaide SA 5001, Australia
| | - Jane A. Endicott
- Department
of Biochemistry, University of Oxford,
South Parks Road, Oxford OX1
3QU, U.K
| | - Martin E. Noble
- Department
of Biochemistry, University of Oxford,
South Parks Road, Oxford OX1
3QU, U.K
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106
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Diaz-Moralli S, Tarrado-Castellarnau M, Miranda A, Cascante M. Targeting cell cycle regulation in cancer therapy. Pharmacol Ther 2013; 138:255-71. [PMID: 23356980 DOI: 10.1016/j.pharmthera.2013.01.011] [Citation(s) in RCA: 247] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 12/26/2012] [Indexed: 01/10/2023]
Abstract
Cell proliferation is an essential mechanism for growth, development and regeneration of eukaryotic organisms; however, it is also the cause of one of the most devastating diseases of our era: cancer. Given the relevance of the processes in which cell proliferation is involved, its regulation is of paramount importance for multicellular organisms. Cell division is orchestrated by a complex network of interactions between proteins, metabolism and microenvironment including several signaling pathways and mechanisms of control aiming to enable cell proliferation only in response to specific stimuli and under adequate conditions. Three main players have been identified in the coordinated variation of the many molecules that play a role in cell cycle: i) The cell cycle protein machinery including cyclin-dependent kinases (CDK)-cyclin complexes and related kinases, ii) The metabolic enzymes and related metabolites and iii) The reactive-oxygen species (ROS) and cellular redox status. The role of these key players and the interaction between oscillatory and non-oscillatory species have proved essential for driving the cell cycle. Moreover, cancer development has been associated to defects in all of them. Here, we provide an overview on the role of CDK-cyclin complexes, metabolic adaptations and oxidative stress in regulating progression through each cell cycle phase and transitions between them. Thus, new approaches for the design of innovative cancer therapies targeting crosstalk between cell cycle simultaneous events are proposed.
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Affiliation(s)
- Santiago Diaz-Moralli
- Faculty of Biology, Department of Biochemistry and Molecular Biology, Universitat de Barcelona, Barcelona, Spain
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107
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TP53 aberrations in chronic lymphocytic leukemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 792:109-31. [PMID: 24014294 DOI: 10.1007/978-1-4614-8051-8_5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
CLL patients harboring TP53 defects remain the most challenging group in terms of designing rational and effective therapy. Irrespective of the treatment employed-chemotherapy, chemoimmunotherapy, or pure biological drugs-median survival of these patients does not exceed 3-4 years. This adverse outcome is caused by a less effective response to therapeutics acting through DNA damage induction and relying on the subsequent initiation of apoptosis as well as by virtually inevitable aggressive relapse. Patient proportions with TP53 defects at diagnosis or before first therapy were reported within the range 5-15 %, but they increase dramatically in pretreated cohorts (reported up to 44 %), and also in patients with Richter transformation (50 % harbor TP53 defects). Currently, most laboratories monitor TP53 defect as presence of 17p deletion using I-FISH, but 23-45 % of TP53-affected patients were shown to harbor only mutation(s). In other patients with intact TP53, the p53 pathway may be impaired by mutations in ATM gene coding for the p53-regulatory kinase; however, prognosis of ATM-defective patients is not as poor as those with TP53 abnormalities. Though many novel agents are under development, the monoclonal antibody alemtuzumab and allogeneic stem cell transplantation remain the basic treatment options for TP53-affected CLL patients.
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108
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Gorlick R, Kolb EA, Houghton PJ, Morton CL, Neale G, Keir ST, Carol H, Lock R, Phelps D, Kang MH, Reynolds CP, Maris JM, Billups C, Smith MA. Initial testing (stage 1) of the cyclin dependent kinase inhibitor SCH 727965 (dinaciclib) by the pediatric preclinical testing program. Pediatr Blood Cancer 2012; 59:1266-74. [PMID: 22315240 PMCID: PMC3349821 DOI: 10.1002/pbc.24073] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/14/2011] [Indexed: 01/28/2023]
Abstract
BACKGROUND SCH 727965 is a novel drug in clinical development that potently and selectively inhibits CDK1, CDK2, CDK5, and CDK9. The activity of SCH 727965 was evaluated against the PPTP's in vitro and in vivo panels. PROCEDURES SCH 727965 was tested against the PPTP in vitro panel using 96 hours exposure at concentrations ranging from 0.1 nM to 1.0 µM. It was tested against the PPTP in vivo panels at a dose of 40 mg/kg administered intraperitoneally twice weekly for 2 weeks and repeated at Day 21 with a total observation period of 6 weeks. RESULTS The median IC(50) value for the cell lines was 7.5 nM, with less than fourfold range between the minimum (3.4 nM) and maximum (11.2 nM) IC(50) values. SCH 727965 demonstrated an activity pattern consistent with cytotoxicity for most of the cell lines. Forty-three xenograft models were studied and SCH 727965 induced significant delays in event free survival distribution compared to control in 23 of 36 (64%) evaluable solid tumor xenografts and in 3 of 7 ALL xenografts. SCH 727965 did not induce objective responses in the solid tumor panels and the best response observed was stable disease for one osteosarcoma xenograft. In the leukemia panel, there were two objective responses with a complete response observed in a single xenograft. CONCLUSIONS SCH 727965 shows an interesting pattern of activity suggesting its potential applicability against selected childhood cancers, particularly leukemias.
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Affiliation(s)
- Richard Gorlick
- The Children's Hospital at Montefiore, Bronx, NY 10467, USA.
| | | | | | | | | | | | - Hernan Carol
- Children’s Cancer Institute Australia for Medical Research, Lowy Cancer Research Centre, UNSW, Randwick, NSW, Australia
| | - Richard Lock
- Children’s Cancer Institute Australia for Medical Research, Lowy Cancer Research Centre, UNSW, Randwick, NSW, Australia
| | | | - Min H. Kang
- Children’s Hospital of Los Angeles, Los Angeles, CA
| | | | - John M. Maris
- Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine and Abramson Family Cancer Research Institute, Philadelphia, PA
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Lu K, Wang X. Therapeutic advancement of chronic lymphocytic leukemia. J Hematol Oncol 2012; 5:55. [PMID: 22980425 PMCID: PMC3465197 DOI: 10.1186/1756-8722-5-55] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/06/2012] [Indexed: 12/20/2022] Open
Abstract
Despite the combinations of chemotherapy with monoclonal antibodies have further improved response rates, chronic lymphocytic leukemia (CLL) remains an incurable disease with an extremely variable course. This article reviews the ongoing clinical advances in the treatment of CLL in both previously untreated and relapsed disease and focuses on the benefit of different therapeutic strategies, the most effective therapy combinations and the potential activity of novel agents. Novel agents and combination therapies have been investigated by several studies in both the upfront and relapsed setting, particularly for patients with 17p deletion, TP53 mutation and fludarabine-refractory CLL. While these agents and combination therapies have improved initial response rates, ongoing studies are continued to determine and improve the efficacy and safety. Despite advancements in the treatment of CLL have led to high response rates, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative option and reduced-intensity conditioning (RIC) allo-HSCT must be strongly considered whenever feasible. As such, ongoing studies of these agents and other novel approaches in clinical development are needed to expand and improve treatment options for CLL patients.
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Affiliation(s)
- Kang Lu
- Department of Hematology, Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Jinan, Shandong, 250021, P R China
| | - Xin Wang
- Department of Hematology, Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Jinan, Shandong, 250021, P R China
- Department of Diagnostics, Shandong University School of Medicine, Jinan, Shandong, 250012, P. R. China
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110
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Baptista MJ, Muntañola A, Calpe E, Abrisqueta P, Salamero O, Fernández E, Codony C, Giné E, Kalko SG, Crespo M, Bosch F. Differential gene expression profile associated to apoptosis induced by dexamethasone in CLL cells according to IGHV/ZAP-70 status. Clin Cancer Res 2012; 18:5924-33. [PMID: 22966019 DOI: 10.1158/1078-0432.ccr-11-2771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Glucocorticoids are part of the therapeutic armamentarium of chronic lymphocytic leukemia (CLL) where it has been suggested that cells with unmutated IGHV genes exhibit higher sensitivity. The mechanisms by which glucocorticoids are active in CLL are not well elucidated. We aimed to ascertain the activity of dexamethasone in CLL cells according to prognosis and to identify the molecular mechanisms that are influencing the response to this drug. EXPERIMENTAL DESIGN Sensitivity to dexamethasone was analyzed ex vivo in 50 CLL and compared according to IGHV mutational status and/or ZAP-70 expression. The response was further compared by gene expression profiling (GEP) of selected cases. Expression of genes of interest was validated by quantitative reverse transcriptase PCR. RESULTS Response to dexamethasone was higher in cases with unmutated IGHV/high ZAP-70 expression, and the levels of induction of the pro-apoptotic Bim protein correlated with the degree of cell death. GEP analysis showed few genes differentially expressed after dexamethasone treatment between mutated and unmutated cases. However, functional annotation analysis showed that unmutated cases had significant enrichment in terms related to apoptosis. Specific analysis of genes of interest conducted in a large series disclosed that in unmutated IGHV cells, FKBP5 expression was higher at baseline and after dexamethasone exposure and that GILZ was more induced by dexamethasone treatment in these cases. CONCLUSIONS Unmutated IGHV/high ZAP-70 CLL cells exhibit better response to dexamethasone treatment, which is accompanied by a differential expression of genes involved in the glucocorticoid receptor pathway and by an increased induction of genes related to apoptosis.
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Affiliation(s)
- Maria Joao Baptista
- Laboratory of Experimental Hematology, Department of Hematology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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111
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Dolečková I, Rárová L, Grúz J, Vondrusová M, Strnad M, Kryštof V. Antiproliferative and antiangiogenic effects of flavone eupatorin, an active constituent of chloroform extract of Orthosiphon stamineus leaves. Fitoterapia 2012; 83:1000-7. [DOI: 10.1016/j.fitote.2012.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/28/2012] [Accepted: 06/02/2012] [Indexed: 12/19/2022]
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112
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Denaro N, Russi EG, Colantonio I, Adamo V, Merlano MC. The role of antiangiogenic agents in the treatment of head and neck cancer. Oncology 2012; 83:108-16. [PMID: 22777379 DOI: 10.1159/000339542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/02/2012] [Indexed: 01/25/2023]
Abstract
Despite progress in the treatment of locally advanced head and neck squamous cell cancer (HNSCC), the prognosis remains dismal and 5-year survival does not exceed 40%. In metastatic and recurrent disease, in spite of the introduction of cetuximab in combination with platinum and fluorouracil, the median overall survival rate remains lower than 11 months. There are many possible reasons for these disappointing results including acquired drug resistance and tumor hypoxia. Angiogenesis plays an important role in HNSCC development and proliferation. Promising preclinical results with antiangiogenic therapies have engendered a number of clinical trials, but so far there have not been any conclusive results on the value of such treatments. This paper aims to review the role of angiogenesis in head and neck cancer and to suggest future perspectives.
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Affiliation(s)
- N Denaro
- Department of Oncology, Santa Croce e Carle General Hospital, Cuneo, Italy.
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113
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Karp JE, Garrett-Mayer E, Estey EH, Rudek MA, Smith BD, Greer JM, Drye DM, Mackey K, Dorcy KS, Gore SD, Levis MJ, McDevitt MA, Carraway HE, Pratz KW, Gladstone DE, Showel MM, Othus M, Doyle LA, Wright JJ, Pagel JM. Randomized phase II study of two schedules of flavopiridol given as timed sequential therapy with cytosine arabinoside and mitoxantrone for adults with newly diagnosed, poor-risk acute myelogenous leukemia. Haematologica 2012; 97:1736-42. [PMID: 22733022 DOI: 10.3324/haematol.2012.062539] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Flavopiridol is a protein-bound, cytotoxic, cyclin dependent kinase inhibitor. A phase II trial of flavopiridol followed by ara-C and mitoxantrone with flavopiridol given by 1-h bolus for adults with newly-diagnosed, poor-risk acute myelogenous leukemia yielded 67% complete remission with median disease-free survival of 13.6 months. DESIGN AND METHODS We compared bolus flavopiridol (50 mg/m(2)/day, Arm A) versus 'hybrid' flavopiridol (30 mg/m(2) over 30 min followed by 40 mg/m(2) over 4 h, Arm B) followed by ara-C and mitoxantrone in 78 patients (39 per arm) with newly diagnosed, poor-risk acute myelogenous leukemia. To mitigate imbalance, patients were stratified by presence or absence of secondary leukemia and therapy for antecedent disorder. RESULTS Death at or before Day 60 occurred in 8% of patients per arm. Complete remission plus complete remission with incomplete recovery was 68% (Arm A, 62%; Arm B, 74%) overall, and 65% or over in both arms for patients with secondary leukemia and leukemia with adverse genetics. In Arm A 91% and in Arm B 86% of patients received chemotherapy and/or allogeneic transplantation in complete remission. Median overall survival for all remission patients has not been reached for either arm, with median disease free survival of 13.6 months for Arm A and of 12.0 months for Arm B. CONCLUSIONS Both flavopiridol schedules produce comparably encouraging results in adults with poor-risk acute myelogenous leukemia. Given the greater ease of bolus administration, we are conducting a randomized phase II study of bolus flavopiridol followed by ara-c and mitoxantrone versus conventional induction therapy for patients aged 70 years and under with intermediate or poor-risk acute myelogenous leukemia. This study is registered at www.clinicaltrials.gov as #NCT 00407966.
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Affiliation(s)
- Judith E Karp
- Division of Hematologic Malignancies, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland 21231-1000, USA.
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114
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Chen S, Dai Y, Pei XY, Myers J, Wang L, Kramer LB, Garnett M, Schwartz DM, Su F, Simmons GL, Richey JD, Larsen DG, Dent P, Orlowski RZ, Grant S. CDK inhibitors upregulate BH3-only proteins to sensitize human myeloma cells to BH3 mimetic therapies. Cancer Res 2012; 72:4225-37. [PMID: 22693249 DOI: 10.1158/0008-5472.can-12-1118] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BH3 mimetic drugs induce cell death by antagonizing the activity of antiapoptotic Bcl-2 family proteins. Cyclin-dependent kinase (CDK) inhibitors that function as transcriptional repressors downregulate the Bcl-2 family member Mcl-1 and increase the activity of selective BH3 mimetics that fail to target this protein. In this study, we determined whether CDK inhibitors potentiate the activity of pan-BH3 mimetics directly neutralizing Mcl-1. Specifically, we evaluated interactions between the prototypical pan-CDK inhibitor flavopiridol and the pan-BH3 mimetic obatoclax in multiple myeloma (MM) cells in which Mcl-1 is critical for survival. Coadministration of flavopiridol and obatoclax synergistically triggered apoptosis in both drug-naïve and drug-resistant MM cells. Mechanistic investigations revealed that flavopiridol inhibited Mcl-1 transcription but increased transcription of Bim and its binding to Bcl-2/Bcl-xL. Obatoclax prevented Mcl-1 recovery and caused release of Bim from Bcl-2/Bcl-xL and Mcl-1, accompanied by activation of Bax/Bak. Whether administered singly or in combination with obatoclax, flavopiridol also induced upregulation of multiple BH3-only proteins, including BimEL, BimL, Noxa, and Bik/NBK. Notably, short hairpin RNA knockdown of Bim or Noxa abrogated lethality triggered by the flavopiridol/obatoclax combination in vitro and in vivo. Together, our findings show that CDK inhibition potentiates pan-BH3 mimetic activity through a cooperative mechanism involving upregulation of BH3-only proteins with coordinate downregulation of their antiapoptotic counterparts. These findings have immediate implications for the clinical trial design of BH3 mimetic-based therapies that are presently being studied intensively for the treatment of diverse hematopoietic malignancies, including lethal multiple myeloma.
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Affiliation(s)
- Shuang Chen
- Division of Hematology/Oncology, Department of Medicine, Virginia Commonwealth University and the Massey Cancer Center, Institute of Molecular Medicine, Richmond, Virginia 23298, USA
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115
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Veliz M, Pinilla-Ibarz J. Treatment of relapsed or refractory chronic lymphocytic leukemia. Cancer Control 2012; 19:37-53. [PMID: 22143061 DOI: 10.1177/107327481201900105] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent advances in the treatment of chronic lymphocytic leukemia (CLL) have moved beyond the traditional use of alkylating agents and purine analogs into regimens combining these two chemotherapy classes with monoclonal antibodies. METHODS This article reviews treatments options for patients with relapsed or refractory CLL. RESULTS Several studies have investigated novel agents in treating patients with 17p deletion, TP53 mutation, and fludarabine-refractory CLL, as well as patients with suboptimal response to intense treatment. These investigational agents include rituximab, alemtuzumab, ofatumumab, bendamustine, high-dose methylprednisolone, lenalidomide, lumiliximab, cyclin-dependent kinase inhibitors, small modular immunopharmaceuticals, Bcl-2 inhibitors, and histone deacetylase inhibitors. While these newer drugs and combination therapies have shown promise as treatment options for CLL, additional studies are needed to determine the immunosuppression, toxicities, and infections associated with their use. CONCLUSIONS Despite improvement in initial overall response rates, most patients relapse and require further treatment. CLL remains incurable with standard therapies due to development of disease refractoriness. As such, novel approaches such as those noted above warrant continued research to improve outcomes for patients with CLL.
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Affiliation(s)
- Marays Veliz
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Actinomycin D induces p53-independent cell death and prolongs survival in high-risk chronic lymphocytic leukemia. Leukemia 2012; 26:2508-16. [PMID: 22743622 DOI: 10.1038/leu.2012.147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent lymphoid malignancy in the elderly of the Western world. Although treatment options have improved over the past two decades, 10-15% of patients still have a poor prognosis and are often resistant to therapy. Aberrations in the p53 pathway, such as a deleted (del17p13) or mutated p53 gene, are highly enriched in this class of patients. In an extensive screen for p53-independent apoptosis inducers, actinomycin D was identified from 1496 substances and shown to induce apoptosis in primary CLL cells derived from high-risk patients including those with aberrant p53, revealing a novel p53-independent mechanism of action. Both pro-survival genes BCL2 and MCL1 are targeted by actinomycin D, in contrast to fludarabine the backbone of current treatment schedules. In the well-established TCL1 transgenic mouse model for high-risk CLL, actinomycin D treatment was more effective in reducing tumor load than fludarabine, with no evidence of resistance after three treatment cycles and an overall survival increase of over 300%. Tumor load reduction was coupled to BCL2 downregulation. Our results identify the clinically approved compound actinomycin D as a potentially valuable treatment option for CLL high-risk patients.
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Woyach JA, Lozanski G, Ruppert AS, Lozanski A, Blum KA, Jones JA, Flynn JM, Johnson AJ, Grever MR, Heerema NA, Byrd JC. Outcome of patients with relapsed or refractory chronic lymphocytic leukemia treated with flavopiridol: impact of genetic features. Leukemia 2012; 26:1442-4. [PMID: 22289993 PMCID: PMC3675648 DOI: 10.1038/leu.2011.375] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
MESH Headings
- Antineoplastic Agents/therapeutic use
- Ataxia Telangiectasia Mutated Proteins
- Biomarkers, Tumor/genetics
- Cell Cycle Proteins/genetics
- Chromosome Deletion
- Cytogenetic Analysis
- DNA-Binding Proteins/genetics
- Drug Resistance, Neoplasm/genetics
- Flavonoids/therapeutic use
- Humans
- In Situ Hybridization, Fluorescence
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Piperidines/therapeutic use
- Protein Serine-Threonine Kinases/genetics
- Risk Factors
- Survival Rate
- Treatment Outcome
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Proteins/genetics
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Affiliation(s)
- Jennifer A. Woyach
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | | | - Amy S. Ruppert
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Arletta Lozanski
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Kristie A. Blum
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Jeffrey Alan Jones
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Joseph M. Flynn
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Amy J. Johnson
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
- Division of Medicinal Chemistry, College of Pharmacy, The Ohio State University
| | - Michael R. Grever
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Nyla A. Heerema
- Division of Cytogenetics, Department of Pathology, The Ohio State University
| | - John C. Byrd
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
- Division of Medicinal Chemistry, College of Pharmacy, The Ohio State University
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Best G, Thompson P, Tam CS. Diagnostic techniques and therapeutic challenges in patients with TP53 dysfunctional chronic lymphocytic leukemia. Leuk Lymphoma 2012; 53:2105-15. [PMID: 22568511 DOI: 10.3109/10428194.2012.692088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Aberrations of the TP53 pathway, whether by deletion or mutation, are increasingly recognized as one of the most important biological risk factors in chronic lymphocytic leukemia. Yet, there is little consensus on how to assess for TP53 defects in the clinic, and very few clinical studies to guide optimal management of such patients. In this review, we discuss the state-of-the-art in the assessment of the TP53 pathway, and review the evidence-base for therapeutic recommendations.
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Affiliation(s)
- Giles Best
- Royal North Shore Hospital, St Leonards, NSW, Australia
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119
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The novel cyclin-dependent kinase inhibitor dinaciclib (SCH727965) promotes apoptosis and abrogates microenvironmental cytokine protection in chronic lymphocytic leukemia cells. Leukemia 2012; 26:2554-7. [PMID: 22791353 DOI: 10.1038/leu.2012.144] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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120
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Xia B, Liu X, Zhou Q, Feng Q, Li Y, Liu W, Liu Z. Disposition of orally administered a promising chemotherapeutic agent flavopiridol in the intestine. Drug Dev Ind Pharm 2012; 39:845-53. [DOI: 10.3109/03639045.2012.682224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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121
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Kharfan-Dabaja MA, Pidala J, Kumar A, Terasawa T, Djulbegovic B. Comparing efficacy of reduced-toxicity allogeneic hematopoietic cell transplantation with conventional chemo-(immuno) therapy in patients with relapsed or refractory CLL: a Markov decision analysis. Bone Marrow Transplant 2012; 47:1164-70. [DOI: 10.1038/bmt.2012.71] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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122
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Jaglowski SM, Byrd JC. Novel therapies and their integration into allogeneic stem cell transplant for chronic lymphocytic leukemia. Biol Blood Marrow Transplant 2012; 18:S132-8. [PMID: 22226097 DOI: 10.1016/j.bbmt.2011.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Over the past decade, numerous advances have been made in elucidating the biology of and improving treatment for chronic lymphocytic leukemia (CLL). These studies have led to identification of select CLL patient groups that generally have short survival dating from time of treatment or initial disease relapse who benefit from more aggressive therapeutic interventions. Allogeneic transplantation represents the only potentially curative option for CLL, but fully ablative regimens applied in the past have been associated with significant morbidity and mortality. Reduced-intensity preparative regimens has made application of allogeneic transplant to CLL patients much more feasible and increased the number of patients proceeding to this modality. Arising from this has been establishment of guidelines where allogeneic stem cell transplantation should be considered in CLL. Introduction of new targeted therapies with less morbidity, which can produce durable remissions has the potential to redefine where transplantation is initiated in CLL. This review briefly summarizes the field of allogeneic stem cell transplant in CLL and the interface of new therapeutics with this modality.
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Affiliation(s)
- Samantha M Jaglowski
- Department of Internal Medicine, Division of Hematology and Oncology, Comprehensive Cancer Center at The Ohio State University, Columbus, Ohio, USA
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123
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Sellner L, Dietrich S, Dreger P, Glimm H, Zenz T. Can prognostic factors be used to direct therapy in chronic lymphocytic leukemia? Curr Hematol Malig Rep 2012; 7:3-12. [PMID: 22237849 DOI: 10.1007/s11899-011-0110-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic lymphocytic leukemia (CLL) shows a heterogeneous clinical course, which can be explained in part by prognostic factors. Most patients do not need treatment at the time of first diagnosis. The identification of prognostic factors is of major interest if strategies can be devised to treat patients according to their individual risk profile or biological subgroup. Currently, in spite of a wealth of prognostic factors, individualized treatment approaches in different genetic or risk groups are the exemption in CLL. This review summarizes the most important prognostic and predictive factors in CLL, with particular emphasis on factors affecting treatment decisions in clinical trials and routine practice.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/analysis
- Humans
- Induction Chemotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Mutation
- Phenotype
- Predictive Value of Tests
- Prognosis
- Risk Assessment
- Risk Factors
- Stem Cell Transplantation
- Time Factors
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Affiliation(s)
- Leopold Sellner
- Department of Medicine V, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany
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Billard C. Design of novel BH3 mimetics for the treatment of chronic lymphocytic leukemia. Leukemia 2012; 26:2032-8. [PMID: 22453662 DOI: 10.1038/leu.2012.88] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Impaired programmed cell death is an important factor in the pathogenesis of chronic lymphocytic leukemia (CLL) and in the development of resistance to chemoimmunotherapy. Hence, the reactivation of apoptotic processes is likely to be a pertinent strategy for circumventing this resistance. Proteins from the Bcl-2 family are critical elements in defective apoptosis. Some compounds induce the apoptosis of CLL cells ex vivo by downregulation of prosurvival members of this family (for example, Bcl-2 and Mcl-1), whereas others act by upregulation of proapoptotic Bcl-2 homology (BH) 3-only members (for example, Noxa and Bim). The concept of BH3 mimetics was prompted by the fact that BH3-only proteins are specific antagonistic ligands of prosurvival Bcl-2 family members. This led to the design of small molecules capable of inhibiting the activity of prosurvival Bcl-2 proteins and inducing apoptosis in leukemia cells in vitro and antileukemic effects in animal models. Several putative or actual BH3 mimetics are currently being trialed in the clinic. Two novel BH3 mimetics that can specifically bind to and antagonize Mcl-1 (a crucial antiapoptotic factor in CLL) have recently been discovered. The evaluation of this type of compound's clinical impact in CLL can now be considered.
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Affiliation(s)
- C Billard
- Centre de Recherche des Cordeliers, UMRS 872 (Equipe 18), Paris, France.
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125
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Böttcher S, Ritgen M, Fischer K, Stilgenbauer S, Busch RM, Fingerle-Rowson G, Fink AM, Bühler A, Zenz T, Wenger MK, Mendila M, Wendtner CM, Eichhorst BF, Döhner H, Hallek MJ, Kneba M. Minimal Residual Disease Quantification Is an Independent Predictor of Progression-Free and Overall Survival in Chronic Lymphocytic Leukemia: A Multivariate Analysis From the Randomized GCLLSG CLL8 Trial. J Clin Oncol 2012; 30:980-8. [DOI: 10.1200/jco.2011.36.9348] [Citation(s) in RCA: 351] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose To determine the clinical significance of flow cytometric minimal residual disease (MRD) quantification in chronic lymphocytic leukemia (CLL) in addition to pretherapeutic risk factors and to compare the prognostic impact of MRD between the arms of the German CLL Study Group CLL8 trial. Patients and Methods MRD levels were prospectively quantified in 1,775 blood and bone marrow samples from 493 patients randomly assigned to receive fludarabine and cyclophosphamide (FC) or FC plus rituximab (FCR). Patients were categorized by MRD into low- (< 10−4), intermediate- (≥ 10−4 to <10−2), and high-level (≥ 10−2) groups. Results Low MRD levels during and after therapy were associated with longer progression-free survival (PFS) and overall survival (OS; P < .0001). Median PFS is estimated at 68.7, 40.5, and 15.4 months for low, intermediate, and high MRD levels, respectively, when assessed 2 months after therapy. Compared with patients with low MRD, greater risks of disease progression were associated with intermediate and high MRD levels (hazard ratios, 2.49 and 14.7, respectively; both P < .0001). Median OS was 48.4 months in patients with high MRD and was not reached for lower MRD levels. MRD remained predictive for OS and PFS in multivariate analyses that included the most important pretherapeutic risk markers in CLL. PFS and OS did not differ between treatment arms within each MRD category. However, FCR induced low MRD levels more frequently than FC. Conclusion MRD levels independently predict OS and PFS in CLL. Therefore, MRD quantification might serve as a surrogate marker to assess treatment efficacy in randomized trials before clinical end points can be evaluated.
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Affiliation(s)
- Sebastian Böttcher
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Matthias Ritgen
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Kirsten Fischer
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Stephan Stilgenbauer
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Raymonde M. Busch
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Günter Fingerle-Rowson
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Anna Maria Fink
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Andreas Bühler
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Thorsten Zenz
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael Karl Wenger
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Myriam Mendila
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Clemens-Martin Wendtner
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Barbara F. Eichhorst
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Hartmut Döhner
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael J. Hallek
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael Kneba
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
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Clifford R, Schuh A. State-of-the-Art Management of Patients Suffering from Chronic Lymphocytic Leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:165-78. [PMID: 22474408 PMCID: PMC3315290 DOI: 10.4137/cmo.s6201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of chronic lymphocytic leukemia (CLL) has evolved dramatically in the last decade. For the first time, clinical intervention has been shown to alter the natural history of the disease. Considerable efforts are focussing on better patient selection and response prediction, and it is expected that the publication of the first 200 CLL genomes will spark new insights into risk stratification of CLL patients. Besides, many new agents are being evaluated on their own and in combination therapy in early and late Phase clinical studies. Here, we provide a general clinical introduction into CLL including diagnosis and prognostic markers followed by a summary of the current state-of-the-art treatment. We point to areas of continued clinical research in particular for patients with co-morbidities and highlight the challenges in managing refractory disease.
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Affiliation(s)
- Ruth Clifford
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Churchill Site, Oxford, OX3 7JL, United Kingdom
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127
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Balakrishnan K, Gandhi V. Protein kinases: emerging therapeutic targets in chronic lymphocytic leukemia. Expert Opin Investig Drugs 2012; 21:409-23. [PMID: 22409342 DOI: 10.1517/13543784.2012.668526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Although protein kinases are primary targets for inhibition in hematological malignancies, until recently their contribution to chronic lymphocytic leukemia (CLL) was poorly understood. Insights into B-cell receptor signaling and its role in regulating key cellular functions have shed light on candidate protein kinases that are aberrantly activated in CLL. In this regard, protein kinases are now considered as potential drug targets in CLL. AREA COVERED This review has covered signaling pathways and associated protein kinases in CLL and the kinase inhibitors currently available in preclinical and clinical investigations. Individual protein kinases that are abnormally active in CLL and the functional consequences of their inhibition are discussed. EXPERT OPINION A growing body of evidence suggests that protein kinases are druggable targets for patients with CLL. The emergence of novel and bio-available kinase inhibitors and their promising clinical activity in CLL underscore the oncogenic role of kinases in leukemogenesis. Further investigations directed towards their role as single agents or in combinations may provide insight into understanding the substantial role of kinase-mediated signal transduction pathways and their inhibition in B- CLL.
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Affiliation(s)
- Kumudha Balakrishnan
- The University of Texas MD Anderson Cancer Center, Department of Experimental Therapeutics, Houston, TX 77030, USA.
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128
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Stephens DM, Ruppert AS, Blum K, Jones J, Flynn JM, Johnson AJ, Ji J, Phelps MA, Grever MR, Byrd JC. Flavopiridol treatment of patients aged 70 or older with refractory or relapsed chronic lymphocytic leukemia is a feasible and active therapeutic approach. Haematologica 2012; 97:423-7. [PMID: 22271900 PMCID: PMC3291598 DOI: 10.3324/haematol.2011.047324] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 09/12/2011] [Accepted: 10/13/2011] [Indexed: 11/09/2022] Open
Abstract
Older chronic lymphocytic leukemia patients have poor outcomes with standard treatments and are underrepresented in clinical trials. We retrospectively reviewed outcomes of refractory chronic lymphocytic leukemia patients in two age categories (≥70 and <70 years) treated with single-agent flavopiridol, a drug active in genomically high-risk patients, during two trials. No significant difference between older and younger patients was observed in response rates (43 vs. 47%) or progression-free survival (median 8.7 vs. 9.9 months, P>0.80). Although overall survival was worse in older patients (median 2.1 vs. 2.4 years, P=0.02); when adjusted for other factors this difference was no longer significant (P≥0.10). With the exception of infections (older 29% vs. younger 62%) no significant association with toxicity was observed. These data demonstrate that flavopiridol administration to older chronic lymphocytic leukemia patients is feasible, tolerable, and may have similar efficacy to that in younger patients. Development of treatment approaches including flavopiridol should be considered for these older patients.
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Affiliation(s)
- Deborah M. Stephens
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Amy S. Ruppert
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Kristie Blum
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Jeffrey Jones
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Joseph M. Flynn
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Amy J. Johnson
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - Jia Ji
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University
| | - Mitch A. Phelps
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University
| | - Michael R. Grever
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
| | - John C. Byrd
- Division of Hematology, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University
- Division of Medicinal Chemistry, College of Pharmacy, The Ohio State University, USA
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129
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Luke JJ, D'Adamo DR, Dickson MA, Keohan ML, Carvajal RD, Maki RG, de Stanchina E, Musi E, Singer S, Schwartz GK. The cyclin-dependent kinase inhibitor flavopiridol potentiates doxorubicin efficacy in advanced sarcomas: preclinical investigations and results of a phase I dose-escalation clinical trial. Clin Cancer Res 2012; 18:2638-47. [PMID: 22374332 DOI: 10.1158/1078-0432.ccr-11-3203] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Dysregulated cyclin-dependent kinases are important to the growth of some sarcomas. Flavopiridol is a pan-CDK inhibitor that has been shown to potentiate chemotherapy. As such, we explored the potentiation of doxorubicin by flavopiridol in sarcoma, in vitro and in vivo, and conducted a phase I trial of flavopiridol with doxorubicin in patients with advanced sarcomas. EXPERIMENTAL DESIGN Sarcoma cell lines and xenografts were treated with flavopiridol alone and in combination with doxorubicin. In the phase I study, doxorubicin and flavopiridol were administered on two flavopiridol schedules; a 1-hour bolus and split dosing as a 30-minute bolus followed by a 4-hour infusion. RESULTS Preclinically, flavopiridol potentiated doxorubicin. In vivo, doxorubicin administered 1 hour before flavopiridol was more active than doxorubicin alone. Clinically, 31 patients were enrolled on protocol and flavopiridol was escalated to target dose in two schedules (90 mg/m(2) bolus; 50 mg/m(2) bolus + 40 mg/m(2) infusion) both in combination with doxorubicin (60 mg/m(2)). Dose-limiting toxicities were neutropenia, leukopenia, and febrile neutropenia but no maximum tolerated dose was defined. Flavopiridol pharmacokinetics showed increasing C(max) with increasing dose. Response Evaluation Criteria in Solid Tumors (RECIST) responses included two partial responses, however, stable disease was seen in 16 patients. Of 12 evaluable patients with progressive well- and dedifferentiated liposarcoma, eight had stable disease greater than 12 weeks. CONCLUSIONS The sequential combination of doxorubicin followed by flavopiridol is well tolerated on both schedules. Disease control was observed in well- and dedifferentiated liposarcoma specifically, a disease in which CDK4 is known to be amplified.
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Affiliation(s)
- Jason J Luke
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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130
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Jones JA, Kraut EH, Deam D, Byrd JC, Grever MR. Hematologic improvement after flavopiridol treatment of pentostatin and rituximab refractory hairy cell leukemia. Leuk Lymphoma 2011; 53:490-1. [PMID: 22165992 DOI: 10.3109/10428194.2011.600484] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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131
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Fatima K, Paracha RZ, Qadri I. Post-transcriptional silencing of Notch2 mRNA in chronic lymphocytic [corrected] leukemic cells of B-CLL patients. Mol Biol Rep 2011; 39:5059-67. [PMID: 22161246 DOI: 10.1007/s11033-011-1301-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 11/30/2011] [Indexed: 12/20/2022]
Abstract
Environmental and genomic stresses induce different pathological conditions and one of them is blood cancer. This escalating load of disease with a constant threat to life requires an intensive comprehensive response. For our understanding about the cancer treatment capabilities, novel medicinal platforms should be strived to explore among the existing conventional and molecular approaches that have already been proven to be successful in fighting against genetic diseases. Several DNA therapeutics previously studied are currently in clinical settings. RNA interfering antisense oligonucleotide (AS-ODN) is the most experimentally advanced molecular therapeutic which has the potential to modify the gene activity resulting in the down regulation of particular protein. In this study, we focused on the inhibition of Notch2 function in B-cell chronic lymphocytic leukemia (B-CLL) by AS-ODN (phosphorothioate oligomers) targeted to the initiation codon region of the Notch2 mRNA. We investigated the in vitro ability of four such oligomers to reduce the expression of Notch2 gene in peripheral blood mononuclear cells from B-CLL patients. Our findings implicate that AS-ODNs specifically designed for the region of 314-333 neucleotides (AS1) of Notch2 inhibits its gene expression better than other AS-ODNs designed for other regions and respond in a dose dependent manner. The results of cell proliferation assay for the evaluation of AS1 in gene silencing, infer that the number of cells were reduced to 80% (P < 0.001). Our results implicate that using the AS-ODNs against specific Notch2 nucleotide sequence can be used as future therapeutic agent with the ability of Notch2 down regulation, which is the root problem in the pathogenicity of B-CLL.
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Affiliation(s)
- Kaneez Fatima
- NUST Centre of Virology and Immunology (NCVI), National University of Sciences and Technology (NUST), Sector H-12, Islamabad, Pakistan
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133
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Abstract
The management of chronic lymphocytic leukemia (CLL) is currently undergoing a profound change. First, several new drugs have been approved (fludarabine, bendamustine and two monoclonal antibodies, alemtuzumab and rituximab). In addition, novel monoclonal antibodies targeting CD20, CD23, CD37 or CD40, as well as drugs designed to interfere with central pathways regulating the cell cycle, the apoptotic machinery, or the leukemic microenvironment (flavopiridol, oblimersen, ABT-263 or lenalidomide) are being tested in clinical trials. Furthermore, improved protocols using reduced-intensity allogeneic progenitor cell transplantation makes it possible to offer this procedure to more patients with CLL. Finally, new prognostic markers that may influence therapeutic decisions have been identified. This review attempts to summarize the current knowledge in this rapidly moving field.
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134
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Reagan JL, Castillo JJ. Ofatumumab for newly diagnosed and relapsed/refractory chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2011; 11:151-60. [PMID: 21342032 DOI: 10.1586/era.10.223] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal antibodies have become an increasingly utilized treatment option for many hematological malignancies, including chronic lymphocytic leukemia (CLL). Ofatumumab is a second-generation fully human anti-CD20 monoclonal antibody that binds to the small extracellular loop of CD20, thereby producing complement-dependent cell lysis and antibody-mediated cell cytotoxicity in cells expressing CD20. Ofatumumab has shown efficacy in the treatment for relapsed or refractory CLL. This success has resulted in the recent US FDA approval of ofatumumab for the treatment of CLL in patients who are refractory to fludarabine and alemtuzumab-based regimens. Major side effects of ofatumumab include infusion reactions, neutropenia and increased risk for infection. This article provides an overview of the current data supporting the use of ofatumumab for CLL and projects the future role of ofatumumab as monotherapy and combination therapy.
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Affiliation(s)
- John L Reagan
- Division of Hematology and Oncology, The Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI 02906, USA
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135
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Blum KA, Ruppert AS, Woyach JA, Jones JA, Andritsos L, Flynn JM, Rovin B, Villalona-Calero M, Ji J, Phelps M, Johnson AJ, Grever MR, Byrd JC. Risk factors for tumor lysis syndrome in patients with chronic lymphocytic leukemia treated with the cyclin-dependent kinase inhibitor, flavopiridol. Leukemia 2011; 25:1444-51. [PMID: 21606960 PMCID: PMC3162125 DOI: 10.1038/leu.2011.109] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/21/2011] [Accepted: 04/13/2011] [Indexed: 01/23/2023]
Abstract
Tumor lysis syndrome (TLS) has been described in over 40% of patients with chronic lymphocytic leukemia treated with the cyclin-dependent kinase inhibitor, flavopiridol. We conducted a retrospective analysis to determine predictive factors for TLS. In 116 patients, the incidence of TLS was 46% (95% CI: 36-55%). In univariable analysis, female gender, greater number of prior therapies, Rai stages III-IV, adenopathy ≥ 10 cm, splenomegaly, del(11q), decreased albumin and increased absolute lymphocyte count, white blood cell count (WBC), β2-microglobulin, and lactate dehydrogenase were associated (P < 0.05) with TLS. In multivariable analysis, female gender, adenopathy ≥ 10 cm, elevated WBC, increased β2-microglobulin, and decreased albumin were associated with TLS (P < 0.05). With respect to patient outcomes, 49 and 44% of patients with and without TLS, respectively, responded to flavopiridol (P = 0.71). In a multivariable analysis, controlling for number of prior therapies, cytogenetics, Rai stage, age and gender, progression-free survival (PFS) was inferior in patients with TLS (P = 0.01). Female patients and patients with elevated β2-microglobulin, increased WBC, adenopathy ≥ 10 cm and decreased albumin were at highest risk and should be monitored for TLS with flavopiridol. TLS does not appear to be predictive of response or improved PFS in patients receiving flavopiridol.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/pharmacokinetics
- Clinical Trials, Phase I as Topic
- Clinical Trials, Phase II as Topic
- Cyclin-Dependent Kinases/antagonists & inhibitors
- Female
- Flavonoids/adverse effects
- Flavonoids/pharmacokinetics
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Male
- Middle Aged
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Staging
- Piperidines/adverse effects
- Piperidines/pharmacokinetics
- Retrospective Studies
- Risk Factors
- Survival Rate
- Tissue Distribution
- Treatment Outcome
- Tumor Lysis Syndrome/etiology
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Affiliation(s)
- K A Blum
- Division of Hematology, Department of Internal Medicine, The Arthur G James Comprehensive Cancer Center and The Ohio State University, Columbus, OH 43210, USA.
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136
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Cicenas J, Valius M. The CDK inhibitors in cancer research and therapy. J Cancer Res Clin Oncol 2011; 137:1409-18. [DOI: 10.1007/s00432-011-1039-4] [Citation(s) in RCA: 181] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 08/12/2011] [Indexed: 12/21/2022]
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137
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Robey RW, Ierano C, Zhan Z, Bates SE. The challenge of exploiting ABCG2 in the clinic. Curr Pharm Biotechnol 2011; 12:595-608. [PMID: 21118093 DOI: 10.2174/138920111795163913] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 04/15/2010] [Indexed: 01/16/2023]
Abstract
ABCG2, or breast cancer resistance protein (BCRP), is an ATP-binding cassette half transporter that has been shown to transport a wide range of substrates including chemotherapeutics, antivirals, antibiotics and flavonoids. Given its wide range of substrates, much work has been dedicated to developing ABCG2 as a clinical target. But where can we intervene clinically and how can we avoid the mistakes made in past clinical trials targeting P-glycoprotein? This review will summarize the normal tissue distribution, cancer tissue expression, substrates and inhibitors of ABCG2, and highlight the challenges presented in exploiting ABCG2 in the clinic. We discuss the possibility of inhibiting ABCG2, so as to increase oral bioavailability or increase drug penetration into sanctuary sites, especially the central nervous system; and at the other end of the spectrum, the possibility of improving ABCG2 function, in the case of gout caused by a single nucleotide polymphism. Together, these aspects of ABCG2/BCRP make the protein a target of continuing interest for oncologists, biologists, and pharmacologists.
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Affiliation(s)
- Robert W Robey
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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138
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Bates DJP, Salerni BL, Lowrey CH, Eastman A. Vinblastine sensitizes leukemia cells to cyclin-dependent kinase inhibitors, inducing acute cell cycle phase-independent apoptosis. Cancer Biol Ther 2011; 12:314-25. [PMID: 21768777 DOI: 10.4161/cbt.12.4.16909] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The efficacy of many chemotherapeutic agents can be attenuated by expression of the anti-apoptotic proteins Bcl-2, Bcl-X(L) and Mcl-1. Flavopiridol and dinaciclib are cyclin-dependent kinase 7 and 9 inhibitors that transcriptionally inhibit expression of Mcl-1. We have investigated the ability of flavopiridol and dinaciclib to sensitize a panel of leukemia cell lines to vinblastine and paclitaxel. Both drugs acutely sensitized most of the leukemia lines to vinblastine, with 100% apoptosis in 4 h. Furthermore, dinaciclib sensitized freshly isolated chronic lymphocytic leukemia cells to vinblastine. This rapid induction of apoptosis was attributed to vinblastine-mediated activation of JNK because (a) flavopiridol and dinaciclib failed to induce apoptosis when combined with non-JNK activating concentrations of vinblastine; (b) JNK inhibitors suppressed JNK activity and prevented apoptosis; (c) flavopiridol did not potentiate apoptosis induced by paclitaxel which does not activate JNK in these cells; and (d) Jurkat cells failed to activate JNK in response to vinblastine and were not sensitive to combinations of vinblastine and flavopiridol or dinaciclib. The rapid induction of apoptosis by this combination in multiple cell systems but not in normal lymphocytes provides justification for performing a clinical trial to assess the efficacy in patients.
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Affiliation(s)
- Darcy J P Bates
- Department of Pharmacology and Toxicology, Dartmouth Medical School, Lebanon, NH, USA
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139
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Andritsos LA, Grever MR. Salvage therapy for relapsed chronic lymphocytic leukemia. Expert Rev Hematol 2011; 4:199-212. [PMID: 21495929 DOI: 10.1586/ehm.11.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic lymphocytic leukemia is a common hematologic malignancy with a highly variable clinical course. While the median age at diagnosis is 72 years of age and fewer than 10% of patients are diagnosed before the age of 60 years, the majority of patients who require therapy will ultimately relapse. Advances in upfront therapy and supportive care have dramatically improved initial responses compared with traditional akylator-based chemotherapy. However, comparable results are not generally observed in the salvage setting. Careful planning that takes into account the duration of the initial response, patient age and/or comorbidities, and cytogenetic and molecular profiles are critical for the successful management of patients with relapsed chronic lymphocytic leukemia.
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140
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Touzeau C, Dousset C, Bodet L, Gomez-Bougie P, Bonnaud S, Moreau A, Moreau P, Pellat-Deceunynck C, Amiot M, Le Gouill S. ABT-737 induces apoptosis in mantle cell lymphoma cells with a Bcl-2high/Mcl-1low profile and synergizes with other antineoplastic agents. Clin Cancer Res 2011; 17:5973-81. [PMID: 21821698 DOI: 10.1158/1078-0432.ccr-11-0955] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Mantle cell lymphoma (MCL) is considered to be incurable. ABT-737 is a BH3 mimetic that targets Bcl-2, which is overexpressed in MCL and implicated in drug resistance. The present work investigated the antitumor effect of ABT-737. EXPERIMENTAL DESIGN Six MCL cell lines and primary MCL cells (n = 13) were used. Sensitivity to ABT-737 was assessed, and expression levels of Bcl-2 and Mcl-1 were analyzed. Finally, ABT-737 was combined with other cytotoxic agents to promote tailored therapy. RESULTS MINO and GRANTA-519 cell lines were highly sensitive to ABT-737 [the median lethal dose (LD₅₀) = 20 and 80 nmol/L, respectively], whereas other cell lines were resistant. In primary MCL cells, 46% of patients' samples were sensitive to ABT-737. The analysis of protein expression levels revealed that both sensitive cell lines and primary MCL cells could be characterized by a Bcl-2(high)/Mcl-1(low) profile, whereas resistant MCL cells contained high levels of Mcl-1. ABT-737 induced a rapid disruption of both Bcl-2/Bax and Bcl-2/Bik complexes. In addition, silencing of Mcl-1 by siRNA sensitized MCL cell lines to ABT-737. Similarly, flavopiridol, which induces Mcl-1 downregulation, in combination with ABT-737 led to a synergistic anti-MCL effect in ABT-737-resistant cell lines. This synergy was also observed when ABT-737 was combined with either bortezomib or cytarabine. CONCLUSIONS The present work shows that ABT-737 induces strong apoptosis in MCL cells expressing a Bcl-2(high)/Mcl-1(low) profile. In ABT-737-resistant MCL cells, downregulation of Mcl-1 overcomes Mcl-1-induced resistance and synergizes ABT-737 effects. Our results strongly support the use of ABT-737 according to the Bcl-2/Mcl-1 tumor cell profiles in the treatment of MCL.
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141
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Abstract
Genomic aberrations are of predominant importance to the biology and clinical outcome of patients with chronic lymphocytic leukemia (CLL), and FISH-based genomic risk classifications are routinely used in clinical decision making in CLL. One of the known limitations of CLL FISH is the inability to comprehensively interrogate the CLL genome for genomic changes. In an effort at overcoming the existing limitations in CLL genome analysis, we have analyzed high-purity DNA isolated from FACS-sorted CD19(+) cells and paired CD3(+) or buccal cells from 255 patients with CLL for acquired genomic copy number aberrations (aCNAs) with the use of ultra-high-density Affymetrix SNP 6.0 arrays. Overall, ≥ 2 subchromosomal aCNAs were found in 39% (100 of 255) of all cases analyzed, whereas ≥ 3 subchromosomal aCNAs were detected in 20% (50 of 255) of cases. Subsequently, we have correlated genomic lesion loads (genomic complexity) with the clinical outcome measures time to first therapy and overall survival. With the use of multivariate analyses incorporating the most important prognostic factors in CLL together with SNP 6.0 array-based genomic lesion loads at various thresholds, we identify elevated CLL genomic complexity as an independent and powerful marker for the identification of patients with aggressive CLL and short survival.
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142
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An antiapoptotic BCL-2 family expression index predicts the response of chronic lymphocytic leukemia to ABT-737. Blood 2011; 118:3579-90. [PMID: 21772052 DOI: 10.1182/blood-2011-03-340364] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The antiapoptotic BCL-2 proteins regulate lymphocyte survival and are over-expressed in lymphoid malignancies, including chronic lymphocytic leukemia. The small molecule inhibitor ABT-737 binds with high affinity to BCL-2, BCL-XL, and BCL-W but with low affinity to MCL-1, BFL-1, and BCL-B. The active analog of ABT-737, navitoclax, has shown a high therapeutic index in lymphoid malignancies; developing a predictive marker for it would be clinically valuable for patient selection or choice of drug combinations. Here we used RT-PCR as a highly sensitive and quantitative assay to compare expression of antiapoptotic BCL-2 genes that are known to be targeted by ABT-737. Our findings reveal that the relative ratio of MCL-1 and BFL-1 to BCL-2 expression provides a highly significant linear correlation with ABT-737 sensitivity (r = 0.6, P < .001). In contrast, antiapoptotic transcript levels, used individually or in combination for high or low affinity ABT-737-binding proteins, could not predict ABT-737 sensitivity. The (MCL-1 + BFL-1)/BCL-2 ratio was validated in a panel of leukemic cell lines subjected to genetic and pharmacologic manipulations. Changes after ABT-737 treatment included increased expression of BFL-1 and BCL-B that may contribute to treatment resistance. This study defines a highly significant BCL-2 expression index for predicting the response of CLL to ABT-737.
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143
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Enhanced detection of chromosomal abnormalities in chronic lymphocytic leukemia by conventional cytogenetics using CpG oligonucleotide in combination with pokeweed mitogen and phorbol myristate acetate. Cancer Genet 2011; 204:77-83. [PMID: 21494579 DOI: 10.1016/j.cancergen.2010.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Reproducible cytogenetic analysis in CLL has been limited by the inability to obtain reliable metaphase cells for analysis. CpG oligonucleotide and cytokine stimulation have been shown to improve metaphase analysis of CLL cytogenetic abnormalities, but is limited by variability in the cytokine receptor levels, stability and biological activity of the cytokine in culture conditions and high costs associated with these reagents. We report here use of a novel, stable CpG, GNKG168 along with pokeweed mitogen (PWM) and phorbol 12-myristate 13-acetate (PMA) for conventional cytogenetic assessment in CLL. We demonstrate that the combined use of GNKG168+PWM/PMA increased the sensitivity of detection of chromosomal abnormalities compared to PWM/PMA (n=207, odds ratio=2.2, p=0.0002) and GNKG168 (n=219, odds ratio=1.5, p=0.0452). Further, a significant increase in sensitivity to detect complexity ≥3 with GNKG168+PWM/PMA compared to GNKG168 alone (odds ratio 8.0, p=0.0022) or PWM/PMA alone (odds ratio 9.6, p=0.0007) was observed. The trend toward detection of higher complexity was significantly greater with GNKG168+PWM/PMA compared to GNKG168 alone (p=0.0412). The increased sensitivity was mainly attributed to the addition of PWM/PMA with GNKG168 because GNKG168 alone showed no difference in sensitivity for detection of complex abnormalities (p=0.17). Comparison of fluorescence in situ hybridization (FISH) results with karyotypic results showed a high degree of consistency, although some complex karyotypes were present in cases with no adverse FISH abnormality. These studies provide evidence for potential use of GNKG168 in combination with PWM and PMA in karyotypic analysis of CLL patient samples to better identify chromosomal abnormalities for risk stratification.
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144
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Schnaiter A, Stilgenbauer S. Refractory chronic lymphocytic leukemia--new therapeutic strategies. Oncotarget 2011; 1:472-82. [PMID: 21317446 DOI: 10.18632/oncotarget.101103] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Treatment outcome of chronic lymphocytic leukemia (CLL) has considerably improved since the introduction of fludarabine (F) as part of the standard therapy. Nevertheless, refractoriness to fludarabine occurs in a significant number of patients and is associated with an unfavorable prognosis. Important risk factors are 17p deletion and/or mutation of TP53. For this subgroup the CD52 antibody alemtuzumab (A) presents a new treatment approach and has already been approved. Meanwhile we have to face also refractoriness to alemtuzumab. Importantly, the monoclonal CD20 antibody ofatumumab has now shown efficacy in F and A double-refractory CLL. The next generation CD20 antibody GA-101 is currently compared to rituximab (R) and will possibly be its more potent successor. Further B-cell antigens are targeted by lumiliximab (CD23), TRU-016 (CD37) and blinatumomab (CD19). Apart from monoclonal antibody therapies, a great number of small molecules are examined for the treatment of refractory and relapsed CLL. Most of these agents aim to overcome apoptosis resistance in CLL cells or influence the microenvironment. Typical targets are regulators of the cell cycle and antiapoptotic molecules like the members of the Bcl-2 family. Up to now the most promising agents appear to be flavopiridol and lenalidomide among others.
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145
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Abstract
Chronic lymphocytic leukaemia (CLL) is the most common form of leukaemia in the Western world. The natural history of CLL is extremely variable with a survival time from initial diagnosis that ranges from 2 to more than 20 years. Understanding the clinical diversity and allowing the subclassification of CLL into various prognostic groups not only assists in predicting future outcome for patients, but also helps to direct treatment decisions. Chlorambucil and fludarabine were the standard therapy for CLL for decades. Randomized studies have reported superior overall response and progression-free survival (PFS) for fludarabine compared with alkylator-based therapy and for the fludarabine-cyclophospamide (FC) combination over fludarabine alone. More recently the addition of rituximab to the FC regimen (R-FC) has shown significant improvement in overall response, PFS and overall survival compared with FC alone. However, there are patients for whom this regimen still provides less satisfactory results. Within the above studies CLL patients who have some of the poorer prognostic markers, such as unmutated IgVH genes and/or high beta-2 microglobulin (B2M), and those who fail to achieve a minimal residual disease (MRD) negative remission are likely to have a shorter PFS compared with those without these features. Various strategies have been explored to improve the outcome for such patients. These include the addition of agents to a frontline R-FC regimen, use of consolidation and consideration of maintenance. The only group that can be clearly identified pretreatment for whom conventional fludarabine-based therapies produce significantly inferior response rates, PFS and overall survival are the patients who harbour a genetic fault; deletion or mutation or a combination of deletion and mutation of tumour protein p53 (TP53). TP53 inactivation is a less common finding at first treatment but becomes much more common in fludarabine-refractory patients. Alemtuzumab and high-dose corticosteroids have been shown to be effective in this group of CLL patients. Trials combining these two agents have shown improved responses, particularly for those patients with bulky nodal disease for whom alemtuzumab alone may be insufficient. Since the duration of responses remains relatively short, suitable patients should be considered for allogeneic stem cell transplantation according to the European Group for Blood and Marrow Transplantation (EBMT) guidelines. Furthermore, there are a number of other new treatments on the horizon, including humanized antibodies directed against novel targets and small-molecule inhibitors.
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Affiliation(s)
- Saman Hewamana
- Department of Haemato-Oncology, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, UK
| | - Claire Dearden
- Department of Haemato-Oncology, The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, Sutton, UK
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146
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Abrisqueta P, Crespo M, Bosch F. Personalizing treatment for chronic lymphocytic leukemia. Expert Rev Hematol 2011; 4:27-35. [PMID: 21322776 DOI: 10.1586/ehm.10.84] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the past few years, more effective therapies have emerged in the treatment of chronic lymphocytic leukemia (CLL); these are mainly combinations of immunotherapy with fludarabine-based regimens. Despite the higher response rates obtained with these more intensive treatments, they may not always be applicable. Patients with several comorbidities have an increased toxicity with these newer therapies. Effective tools to distinguish between fit and nonfit patients and new therapeutic approaches suitable for fragile patients with CLL are therefore necessary. Moreover, there is still a subset of patients who are refractory to standard fludarabine-based treatments who continue to have very poor survival. Efforts to understand the mechanisms of resistance to treatment in order to develop new therapeutic agents for those patients are mandatory. Finally, advances in the knowledge of the pathogenesis of CLL are promoting the emergence of drugs directed to new biological targets of this disease. Consequently, trials exploring the toxicity profile and efficacy of these new therapeutic agents, alone or in combination with standard treatments, are warranted.
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Affiliation(s)
- Pau Abrisqueta
- Department of Hematology, University Hospital of Vall d'Hebron 119-129, 08035 Barcelona, Spain
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147
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Phase I study of PD 0332991, a cyclin-dependent kinase inhibitor, administered in 3-week cycles (Schedule 2/1). Br J Cancer 2011; 104:1862-8. [PMID: 21610706 PMCID: PMC3111206 DOI: 10.1038/bjc.2011.177] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: This phase I, open-label, first-in-human study determined dose-limiting toxicities (DLTs) and maximum tolerated dose (MTD) of PD 0332991, an oral cyclin-dependent kinase 4/6 inhibitor with potent anti-proliferative activity in vitro/vivo. Methods: A total of 33 patients with retinoblastoma protein-positive advanced solid tumours or non-Hodgkin's lymphoma refractory to standard therapy or for which no therapy was available received PD 0332991 once daily (QD) for 14 days followed by 7 days off treatment (21-day cycles; Schedule 2/1). Results: Six patients had DLTs (18% four receiving 200 mg QD; two receiving 225 mg QD); the MTD was 200 mg QD. Treatment-related, non-haematological adverse events occurred in 29 patients (88%) during cycle 1 and 27 patients (82%) thereafter. Adverse events were generally mild–moderate. Of 31 evaluable patients, one with testicular cancer achieved a partial response; nine had stable disease (⩾10 cycles in three cases). PD 0332991 was slowly absorbed (mean Tmax 4.2 h) and eliminated (mean half-life 26.7 h). Volume of distribution was large (mean 3241 l) with dose-proportional exposure. Using a maximum effective concentration model, neutropenia was proportional to exposure. Conclusion: PD 0332991 was generally well tolerated, with DLTs related mainly to myelosuppression. The MTD, 200 mg QD, is recommended for phase II study.
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148
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Wickremasinghe RG, Prentice AG, Steele AJ. p53 and Notch signaling in chronic lymphocytic leukemia: clues to identifying novel therapeutic strategies. Leukemia 2011; 25:1400-7. [PMID: 21566651 DOI: 10.1038/leu.2011.103] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The p53 tumor suppressor protein has a key role in the induction of apoptosis of chronic lymphocytic leukemia (CLL) cells. Abnormalities within the p53 pathway identify a subset of patients with a poor prognosis. This review describes recent advances in understanding the mechanisms that regulate p53 levels and the role of p53 in the control of the cell cycle and of apoptosis. The classical model of p53-mediated apoptosis emphasizes the transcriptional activation of proapoptotic genes. In contrast, a novel model emphasizes p53's non-transcriptional actions as the major route of apoptosis induction, whereas its transcriptional arm predominantly upregulates antiapoptotic genes, thus providing a negative feedback mechanism that limits apoptosis. Further studies have identified the Notch pathway as a candidate p53-induced antiapoptotic mechanism. In contrast to the classical model, the novel model predicts that pharmacological inhibition of p53's transcriptional function or of the Notch signaling pathway will augment apoptosis induction by cytotoxic agents. Therapeutic strategies based on the novel model, which we review here for the first time, may significantly augment the antitumor actions of cytotoxic agents in CLL and in other malignancies.
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Affiliation(s)
- R G Wickremasinghe
- Department of Haematology, Cancer Institute, University College Hospital Medical School, London, UK.
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149
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Bose P, Qubaiah O. A review of tumour lysis syndrome with targeted therapies and the role of rasburicase. J Clin Pharm Ther 2011; 36:299-326. [PMID: 21501203 DOI: 10.1111/j.1365-2710.2011.01260.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tumour lysis syndrome (TLS) is an oncologic emergency with potentially devastating consequences classically associated with cytotoxic chemotherapy. In recent years, molecularly targeted drugs have assumed an increasingly important role in cancer therapeutics. The possibility of TLS is often overlooked in this setting. Rasburicase, a recombinant urate oxidase, is remarkably effective in treating hyperuricemia, thought to be central to the pathogenesis of renal injury in TLS. Our objective is to review the literature on TLS especially as it pertains to targeted therapies and summarize current knowledge and provide future directions regarding the role of rasburicase in the management of TLS. METHODS A MEDLINE search was conducted using PubMed and the keyphrase 'tumor lysis syndrome' to identify articles describing TLS with a broad range of novel anti-cancer agents. Meeting abstracts were also reviewed. Additionally, the biomedical literature was searched using the keyword 'rasburicase'. RESULTS AND DISCUSSION Tumour lysis syndrome has been described with nearly every class of 'targeted therapy'. This is not surprising as any drug causing death of cancer cells by any mechanism may lead to TLS in the appropriate setting. Although there is a wealth of evidence suggesting that rasburicase is extremely effective in correcting hyperuricemia, prospective trials showing that it improves hard outcomes such as acute renal failure, need for dialysis and mortality are lacking. Furthermore, much lower doses and durations of therapy than approved appear to be effective in controlling hyperuricemia, potentially leading to enormous cost savings. WHAT IS NEW AND CONCLUSION Any effective cancer therapy can lead to TLS. Physicians should consider the risk of TLS on a case-by-case basis and determine appropriate prophylaxis. The role of rasburicase continues to evolve. Randomized controlled trials evaluating clinically relevant outcomes are needed.
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Affiliation(s)
- P Bose
- Division of Hematology/Oncology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA.
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150
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Wickremasinghe RG, Prentice AG, Steele AJ. Aberrantly activated anti-apoptotic signalling mechanisms in chronic lymphocytic leukaemia cells: clues to the identification of novel therapeutic targets. Br J Haematol 2011; 153:545-56. [PMID: 21501136 DOI: 10.1111/j.1365-2141.2011.08676.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is the commonest haematological malignancy in the western world and is incurable by cytotoxic therapy. Considerable research effort has identified the signal transduction pathways in CLL cells that contribute to anti-apoptotic signalling. Some pathways are constitutively activated in CLL cells but upregulated in normal cells only when protein tyrosine kinases (PTKs) are activated by ligands. This review describes which PTKs are aberrantly activated in CLL cells and are potential targets for inhibition. Additional potential targets within pathways downstream of these PTKs include Mek/Erk, mTorc1, protein kinase C, PI-3 kinase/Akt, nuclear factor-κB and cyclin-dependent protein kinase. Numerous studies have identified chemical agents and antibodies that selectively kill CLL cells, irrespective of their genetic resistance to conventional chemotherapeutic agents, and which can overcome cytoprotective microenvironmental signalling. These studies have resulted in identification of novel therapies, some of which are currently undergoing clinical trials. In vitro and animal model studies and clinical trials could determine which inhibitors of which targets are the likely to be most effective and least toxic either singly or in combination.
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