301
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Standardisation of molecular monitoring for chronic myeloid leukaemia. Best Pract Res Clin Haematol 2009; 22:355-65. [DOI: 10.1016/j.beha.2009.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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302
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Kim D, Kim DW, Cho BS, Goh HG, Kim SH, Kim WS, Lee J, Kweon IY, Park SH, Yoon JH, Kim ND, Chun H. Structural modeling of V299L and E459K Bcr-Abl mutation, and sequential therapy of tyrosine kinase inhibitors for the compound mutations. Leuk Res 2009; 33:1260-5. [DOI: 10.1016/j.leukres.2008.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 12/18/2008] [Accepted: 12/21/2008] [Indexed: 11/24/2022]
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303
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Clark RE. Facts and uncertainties in monitoring treatment response in chronic myeloid leukaemia. Leuk Res 2009; 33:1151-5. [DOI: 10.1016/j.leukres.2009.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 04/03/2009] [Accepted: 04/04/2009] [Indexed: 11/29/2022]
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304
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Jabbour E, Cortés JE, Kantarjian H. Second-line therapy and beyond resistance for the treatment of patients with chronic myeloid leukemia post imatinib failure. CLINICAL LYMPHOMA & MYELOMA 2009; 9 Suppl 3:S272-9. [PMID: 19778852 DOI: 10.3816/clm.2009.s.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic myeloid leukemia (CML) is characterized at the molecular level by the presence of the Philadelphia chromosome (Ph) and the resultant oncogenic signaling by the BCR-ABL fusion protein. The treatment and outlook for CML were revolutionized by the introduction of imatinib, but resistance is a substantial barrier to successful treatment in many patients. Introduction of the second-generation tyrosine kinase inhibitors (TKI) dasatinib and nilotinib has provided effective therapeutic options for many patients with resistance to front-line imatinib. However, the T315I mutation remains a significant clinical issue because it is insensitive to all currently available agents. A number of new agents are in development and many hold the promise of activity in T315I-mutated disease. Successful treatment of patients with disease harboring T315I might lie in the effective combination or sequencing of these new agents with existing TKI therapies.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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305
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Signalling pathways in prostate carcinogenesis: potentials for molecular-targeted therapy. Clin Sci (Lond) 2009; 117:209-28. [PMID: 19663810 DOI: 10.1042/cs20080391] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Prostate cancer represents a major health issue and its incidence is rising globally. In developed countries, prostate cancer is the most frequently diagnosed cancer and the second most common cause of death from cancer in men. Androgen deprivation reduces tumour activity in approx. 80% of patients with advanced disease, but most tumours relapse within 2 years to an incurable hormone-resistant state. Even for patients with early disease at the time of diagnosis, a proportion of patients will unfortunately develop relapsed disease following radical therapy. Treatment options for patients with hormone-resistant prostate cancer are very limited and, even with toxic therapy, such as docetaxel, the life expectancy is only improved by a median of 2 months. Advances in molecular oncology have identified key signalling pathways that are considered to be driving events in prostate carcinogenesis. The activation of multiple signalling pathways increases further the possibility of cross-talk among 'linear' signalling cascades. Hence signalling networks that may incorporate distinct pathways in prostate cancer, particularly in hormone-resistant disease, are increasingly appreciated in drug development programmes. With the development of potent small-molecule inhibitors capable of specifically suppressing the activities of individual 'linear' cascades, it may be that, by combining these agents as guided by the molecular signature of prostate cancer, a more efficient therapeutic regime may be developed. Therefore the present review focuses on evidence of abnormal signalling in prostate cancer and the potential of these targets in drug development, and incorporates key findings of relevant clinical trials to date.
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306
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Abstract
Molecular monitoring in chronic myeloid leukemia (CML) is a powerful tool to document treatment responses and predict relapse. Nonetheless, the proliferation of clinical trials and "guidelines" using the molecular endpoints of CML has outpaced practice norms, commercial laboratory application, and reimbursement practices, leaving some anxiety (if not confusion and despair) about molecular monitoring in the day-to-day treatment of CML. This article will try to address these issues by describing how I monitor CML, which, in summary, is with interest and without panic.
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307
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Hughes T, Saglio G, Branford S, Soverini S, Kim DW, Müller MC, Martinelli G, Cortes J, Beppu L, Gottardi E, Kim D, Erben P, Shou Y, Haque A, Gallagher N, Radich J, Hochhaus A. Impact of baseline BCR-ABL mutations on response to nilotinib in patients with chronic myeloid leukemia in chronic phase. J Clin Oncol 2009; 27:4204-10. [PMID: 19652056 DOI: 10.1200/jco.2009.21.8230] [Citation(s) in RCA: 238] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Nilotinib is a second-generation tyrosine kinase inhibitor indicated for the treatment of patients with chronic myeloid leukemia (CML) in chronic phase (CP; CML-CP) and accelerated phase (AP; CML-AP) who are resistant to or intolerant of prior imatinib therapy. In this subanalysis of a phase II study of nilotinib in patients with imatinib-resistant or imatinib-intolerant CML-CP, the occurrence and impact of baseline and newly detectable BCR-ABL mutations were assessed. PATIENTS AND METHODS Baseline mutation data were assessed in 281 (88%) of 321 patients with CML-CP in the phase II nilotinib registration trial. RESULTS Among imatinib-resistant patients, the frequency of mutations at baseline was 55%. After 12 months of therapy, major cytogenetic response (MCyR) was achieved in 60%, complete cytogenetic response (CCyR) in 40%, and major molecular response (MMR) in 29% of patients without baseline mutations versus 49% (P = .145), 32% (P = .285), and 22% (P = .366), respectively, of patients with mutations. Responses in patients who harbored mutations with high in vitro sensitivity to nilotinib (50% inhibitory concentration [IC(50)] <or= 150 nM) or mutations with unknown nilotinib sensitivity were equivalent to those responses for patients without mutations (not significant). Patients with mutations that were less sensitive to nilotinib in vitro (IC(50) > 150 nM; Y253H, E255V/K, F359V/C) had less favorable responses, as 13%, 43%, and 9% of patients with each of these mutations, respectively, achieved MCyR; none achieved CCyR. CONCLUSION For most patients with imatinib resistance and with mutations, nilotinib offers a substantial probability of response. However, mutational status at baseline may influence response. Less sensitive mutations that occurred at three residues defined in this study, as well as the T315I mutation, may be associated with less favorable responses to nilotinib.
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Affiliation(s)
- Timothy Hughes
- Institute of Medical and Veterinary Science, Hanson Center for Cancer Research, Department of Hematology, Adelaide, 5000, Australia.
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308
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Baccarani M. New directions in the treatment of patients with chronic myeloid leukemia: introduction. Semin Hematol 2009; 46:S1-4. [PMID: 19621542 DOI: 10.1053/j.seminhematol.2009.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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309
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Quintás-Cardama A, Cortes JE, O'Brien S, Ravandi F, Borthakur G, Liu D, Bleickardt E, Chen TT, Kantarjian HM. Dasatinib early intervention after cytogenetic or hematologic resistance to imatinib in patients with chronic myeloid leukemia. Cancer 2009; 115:2912-21. [PMID: 19402171 DOI: 10.1002/cncr.24325] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although many patients with chronic myeloid leukemia (CML) respond well to imatinib therapy, a significant proportion loses their initial response. Loss of response on imatinib is often because of BCR-ABL mutations. Dasatinib is a 325-fold more potent inhibitor of Bcr-Abl than imatinib and has been associated with high rates of durable responses in patients with CML in chronic phase (CP) after imatinib failure. METHODS To determine the optimal time for initiating dasatinib after loss of response on imatinib, data from dasatinib trials in CML-CP were analyzed. Patients were grouped according to whether they received early intervention with dasatinib (ie, after cytogenetic recurrence on imatinib), rather than after both cytogenetic and hematologic recurrence. RESULTS Overall, 72% of patients who received dasatinib after loss of a major cytogenetic response (MCyR) on imatinib achieved a complete cytogenetic response (CCyR) compared with 42% of patients who were treated after loss of both MCyR and complete hematologic response (CHR). Event-free survival (EFS) also was higher after earlier dasatinib treatment (24-month EFS rates: 89% after loss of MCyR on imatinib vs 29% after loss of both MCyR and CHR). Among patients who were treated after loss of CHR on imatinib with no prior MCyR, 26% achieved a CCyR with dasatinib, and the 24-month EFS rate was 64%. In all 3 groups, CCyR rates were similar in patients with or without pre-existing BCR-ABL mutations. CONCLUSIONS The results of the current study suggested that optimal outcomes are achieved when dasatinib is administered early after imatinib resistance.
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Affiliation(s)
- Alfonso Quintás-Cardama
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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310
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Mascarenhas CC, Cunha AF, Miranda EC, Zulli R, Silveira RA, Costa FF, Pagnano KBB, De Souza CA. New mutations detected by denaturing high performance liquid chromatography during screening of exon 6 bcr-abl mutations in patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors. Leuk Lymphoma 2009; 50:1148-54. [PMID: 19557636 DOI: 10.1080/10428190902930496] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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311
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Class effects of tyrosine kinase inhibitors in the treatment of chronic myeloid leukemia. Leukemia 2009; 23:1698-707. [PMID: 19474800 DOI: 10.1038/leu.2009.111] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Tyrosine kinase inhibitors have revolutionized the treatment of chronic myeloid leukemia (CML), offering patients several targeted therapeutic options that provide the possibility of sustained remissions and prolonged survival. With the availability of imatinib, nilotinib and dasatinib, physicians must weigh the efficacy and safety profile of each agent when choosing the best therapeutic option for individual patients. Each agent targets tyrosine kinases within the cell uniquely to cause the desired antiproliferative effect. In addition to inhibiting the BCR-ABL kinase, imatinib and nilotinib target the same array of other tyrosine kinases, including c-KIT and platelet-derived growth factor receptor (PDGFR), albeit with differing potencies. While targeting BCR-ABL with the highest potency among approved agents in CML, dasatinib also targets a broad array of off-target kinases, including SRC family members, PDGFR and EPHB4. The differences in kinase inhibition profiles among these agents in vitro probably account for the differing clinical safety profiles of these agents. This paper reviews the various kinases inhibited by imatinib, nilotinib and dasatinib, and describes the potential impact of kinase inhibition on the efficacy and safety of each agent.
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312
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Jia HY, Wu JX, Zhu XF, Chen JM, Yang SP, Yan HJ, Tan L, Zeng YX, Huang W. ZD6474 inhibits Src kinase leading to apoptosis of imatinib-resistant K562 cells. Leuk Res 2009; 33:1512-9. [PMID: 19394692 DOI: 10.1016/j.leukres.2009.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 02/19/2009] [Accepted: 03/25/2009] [Indexed: 02/02/2023]
Abstract
ZD6474 is an orally available, small-molecule tyrosine kinase inhibitor. This study explores the effect of ZD6474 on imatinib-resistant K562 cell lines, which show markedly increased SRC family kinases (SFKs) activity. ZD6474 induces growth arrest and apoptosis of imatinib-resistant and parental K562 cells, as well as inhibition of Src activity and its downstream effectors, the anti-apoptotic Bcl-2 family. ZD6474 treatment also inhibits the activity of STAT3 and reactivation of its activity results in suppression of the anti-tumor effects of SFKs inhibitors. A single oral administration of ZD6474 produced dose-dependent inhibition of imatinib-resistant K562 cells xenograft tumors. These results suggest that clinical assessment of ZD6474 against imatinib-resistant CML is warranted.
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Affiliation(s)
- Hong-Yun Jia
- State Key Laboratory of Oncology in South China, Cancer Center, Sun Yat-sen University, Guangzhou, PR China
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313
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Koldehoff M, Elmaagacli AH. Therapeutic targeting of gene expression by siRNAs directed against BCR-ABL transcripts in a patient with imatinib-resistant chronic myeloid leukemia. Methods Mol Biol 2009; 487:451-66. [PMID: 19301661 DOI: 10.1007/978-1-60327-547-7_22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Within the recent years, RNA interference (RNAi) has become an almost-standard method for in vitro knockdown of any target gene of interest. Now, one major focus is to further explore its potential in vivo, including the development of novel therapeutic strategies. From the mechanism, it becomes clear that small interfering RNAs (siRNAs) play a pivotal role in triggering RNAi. Thus, the efficient delivery of target gene-specific siRNAs is one major challenge in the establishment of therapeutic RNAi. Here we show that in vivo application of targeted nonvirally delivered synthetic bcr-abl siRNA in a female patient with recurrent Philadelphia chromosome positive chronic myeloid leukemia (CML) resistant to imatinib (Y253F mutation) and chemotherapy after allogeneic hematopoietic stem cell transplantation can silence the expression of bcr-abl gene. We found a remarkable inhibition of the overexpressed bcr-abl oncogene resulting in increased apoptosis of CML cells. In vivo siRNA application was well tolerated without any clinically adverse events. Our findings imply that the clinical application of synthetic siRNA is feasible, safe and has real potential for genetic-based therapies using synthetic nonviral carriers.
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Affiliation(s)
- Michael Koldehoff
- Department of Bone Marrow Transplantation, University Hospital of Essen, Essen, Germany
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314
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Bellodi C, Lidonnici MR, Hamilton A, Helgason GV, Soliera AR, Ronchetti M, Galavotti S, Young KW, Selmi T, Yacobi R, Van Etten RA, Donato N, Hunter A, Dinsdale D, Tirrò E, Vigneri P, Nicotera P, Dyer MJ, Holyoake T, Salomoni P, Calabretta B. Targeting autophagy potentiates tyrosine kinase inhibitor-induced cell death in Philadelphia chromosome-positive cells, including primary CML stem cells. J Clin Invest 2009; 119:1109-23. [PMID: 19363292 DOI: 10.1172/jci35660] [Citation(s) in RCA: 454] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 02/11/2009] [Indexed: 12/30/2022] Open
Abstract
Imatinib mesylate (IM), a potent inhibitor of the BCR/ABL tyrosine kinase, has become standard first-line therapy for patients with chronic myeloid leukemia (CML), but the frequency of resistance increases in advancing stages of disease. Elimination of BCR/ABL-dependent intracellular signals triggers apoptosis, but it is unclear whether this activates additional cell survival and/or death pathways. We have shown here that IM induces autophagy in CML blast crisis cell lines, CML primary cells, and p210BCR/ABL-expressing myeloid precursor cells. IM-induced autophagy did not involve c-Abl or Bcl-2 activity but was associated with ER stress and was suppressed by depletion of intracellular Ca2+, suggesting it is mechanistically nonoverlapping with IM-induced apoptosis. We further demonstrated that suppression of autophagy using either pharmacological inhibitors or RNA interference of essential autophagy genes enhanced cell death induced by IM in cell lines and primary CML cells. Critically, the combination of a tyrosine kinase inhibitor (TKI), i.e., IM, nilotinib, or dasatinib, with inhibitors of autophagy resulted in near complete elimination of phenotypically and functionally defined CML stem cells. Together, these findings suggest that autophagy inhibitors may enhance the therapeutic effects of TKIs in the treatment of CML.
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315
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Bixby DL, Talpaz M. Efficacy of various doses and schedules of second-generation tyrosine kinase inhibitors. ACTA ACUST UNITED AC 2009; 8 Suppl 3:S95-S106. [PMID: 19254887 DOI: 10.3816/clm.2008.s.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Imatinib is one of the most potent cancer therapeutic agents identified to date. Before the introduction of this tyrosine kinase inhibitor (TKI), 5-year survival in chronic myeloid leukemia (CML) was approximately 40%-60%, but since the introduction of imatinib, overall survival has increased to approximately 90% for patients with chronic-phase disease. However, nearly one fifth of patients are intolerant or resistant to imatinib, resulting in patients with persistent or progressive disease. Recent research has identified a number of additional compounds that more efficiently inhibit the Abl tyrosine kinase and additional kinases that potentially play a role in imatinib resistance. The advent of dasatinib and nilotinib has provided additional options for patients with progressive disease. A number of phase II clinical trials have recently demonstrated that these second-generation TKIs are well tolerated and effective in patients with Philadelphia chromosome-positive (Ph+) leukemias. Recent clinical trial developments raise questions regarding the proper dosage and schedule of these newer agents as well as the timing of their use in the treatment of patients with CML. Additionally, the development of nonoverlapping resistance patterns with sequential drug exposure argues for the possibility of a drug selection scheme that might limit the development of resistant disease. As the era of personalized medicine has begun to take shape in the 21st century, the addition of newer TKIs might facilitate this trend in the treatment of Ph+ leukemias.
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Affiliation(s)
- Dale L Bixby
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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316
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Quintás-Cardama A, Kantarjian HM, Cortes JE. Mechanisms of primary and secondary resistance to imatinib in chronic myeloid leukemia. Cancer Control 2009; 16:122-31. [PMID: 19337198 DOI: 10.1177/107327480901600204] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Although the vast majority of patients with chronic myeloid leukemia (CML) respond to the tyrosine kinase inhibitor (TKI) imatinib mesylate, resistance might occur de novo or during treatment. METHODS The authors reviewed the known mechanisms of primary and secondary resistance to imatinib and other TKIs used in the management of CML. RESULTS Mutations within the kinase domain of BCR-ABLI account for 30% to 40% of cases of imatinib resistance. Other mechanisms include BCR-ABLI amplification, overexpression of the SRC family of kinases, and pharmacokinetic and pharmacodynamic factors. CONCLUSIONS Although not all resistance mechanisms have been identified and understood, several agents based on the known mechanisms have already been designed and developed and are beginning clinical trials.
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Affiliation(s)
- Alfonso Quintás-Cardama
- Department of Leukemia at The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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317
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Verma D, Fava C, Kantarjian H, Cortes J. Complexity of BCR-ABL kinase domain mutations during the course of therapy with tyrosine kinase inhibitors in chronic myeloid leukemia. Am J Hematol 2009; 84:256-7. [PMID: 19260121 DOI: 10.1002/ajh.21366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
MESH Headings
- Aged
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Alkylating/therapeutic use
- Benzamides
- Dasatinib
- Drug Resistance, Neoplasm/genetics
- Female
- Fusion Proteins, bcr-abl/genetics
- Harringtonines/therapeutic use
- Homoharringtonine
- Humans
- Hydroxyurea/therapeutic use
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Mutagenesis
- Mutation, Missense
- Piperazines/pharmacology
- Piperazines/therapeutic use
- Point Mutation
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Protein Structure, Tertiary/genetics
- Pyrimidines/pharmacology
- Pyrimidines/therapeutic use
- Thiazoles/pharmacology
- Thiazoles/therapeutic use
- Treatment Failure
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318
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Mauro MJ. Tailoring Tyrosine Kinase Inhibitor Therapy in Chronic Myeloid Leukemia. Cancer Control 2009; 16:108-21. [DOI: 10.1177/107327480901600203] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael J. Mauro
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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319
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Jabbour E, Soverini S. Understanding the role of mutations in therapeutic decision making for chronic myeloid leukemia. Semin Hematol 2009; 46:S22-6. [PMID: 19621546 DOI: 10.1053/j.seminhematol.2009.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In patients with chronic myeloid leukemia (CML) resistant to imatinib, resistance is commonly associated with mutations in the BCR-ABL protein. Approximately 85% to 90% of resistance-associated mutations occur within the ABL kinase domain, and confer resistance either directly, by blocking imatinib binding, or indirectly, by altering the conformation of BCR-ABL. The degree of resistance depends on the mutation, with some remaining sensitive to imatinib. Imatinib dose escalation may overcome resistance in some of these patients or therapy can be switched to the second-generation tyrosine kinase inhibitors (TKIs) nilotinib or dasatinib. The long-term efficacy of second-generation TKIs may also be related to specific BCR-ABL mutations, with the T315I mutant remaining resistant to all currently available TKIs. Other treatments, including investigational agents, may be options for patients with this mutation. The choice of therapy should be guided by multiple factors, including mutational analysis, disease phase, patient characteristics, and the safety profile of the agents.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 428, Houston, TX 77030, USA.
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320
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Ma W, Kantarjian H, Yeh CH, Zhang ZJ, Cortes J, Albitar M. BCR-ABL truncation due to premature translation termination as a mechanism of resistance to kinase inhibitors. Acta Haematol 2009; 121:27-31. [PMID: 19332983 DOI: 10.1159/000210060] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 02/05/2009] [Indexed: 01/18/2023]
MESH Headings
- Animals
- Drug Resistance, Neoplasm/drug effects
- Drug Resistance, Neoplasm/genetics
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Mutation
- Peptide Chain Termination, Translational/drug effects
- Peptide Chain Termination, Translational/genetics
- Philadelphia Chromosome
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
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Affiliation(s)
- Wanlong Ma
- Department of Hematology and Oncology, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, USA
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321
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Jabbour E, Kantarjian HM, Jones D, Shan J, O'Brien S, Reddy N, Wierda WG, Faderl S, Garcia-Manero G, Verstovsek S, Rios MB, Cortes J. Imatinib mesylate dose escalation is associated with durable responses in patients with chronic myeloid leukemia after cytogenetic failure on standard-dose imatinib therapy. Blood 2009; 113:2154-60. [PMID: 19060245 PMCID: PMC4081392 DOI: 10.1182/blood-2008-04-154344] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 11/23/2008] [Indexed: 02/03/2023] Open
Abstract
We assessed the long-term efficacy of imatinib dose escalation in 84 patients with chronic myeloid leukemia in chronic phase who met the criteria of failure to standard-dose imatinib. Twenty-one patients with hematologic failure and 63 with cytogenetic failure had their imatinib dose escalated from 400 to 800 mg daily (n = 72) or from 300 to 600 mg daily (n = 12). After a median follow-up of 61 months from dose escalation, 69% remained alive. Complete cytogenetic responses were achieved in 40%; including 52% of patients with cytogenetic failure and 5% of those with hematologic failure. The estimated 2- and 3-year event-free survival and overall survival rates were 57% and 47%, and 84% and 76%, respectively. Responses were long-lasting; 88% of patients with major cytogenetic response sustained their response beyond 2 years. Treatment was well tolerated, with 76% of patients, at 12 months, continuing to receive imatinib at 100% of the intended dose. In conclusion, imatinib dose escalation can induce sustained responses in a subset of patients with cytogenetic failure and a previous cytogenetic response to standard-dose imatinib.
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MESH Headings
- Adolescent
- Adult
- Aged
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Benzamides
- DNA Mutational Analysis
- Disease-Free Survival
- Female
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- In Situ Hybridization, Fluorescence
- Kaplan-Meier Estimate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Male
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/mortality
- Piperazines/administration & dosage
- Piperazines/adverse effects
- Prognosis
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Reverse Transcriptase Polymerase Chain Reaction
- Treatment Outcome
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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322
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Comparison of imatinib 400 mg and 800 mg daily in the front-line treatment of high-risk, Philadelphia-positive chronic myeloid leukemia: a European LeukemiaNet Study. Blood 2009; 113:4497-504. [PMID: 19264678 DOI: 10.1182/blood-2008-12-191254] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Imatinib mesylate (IM), 400 mg daily, is the standard treatment of Philadelphia-positive (Ph(+)) chronic myeloid leukemia (CML). Preclinical data and results of single-arm studies raised the suggestion that better results could be achieved with a higher dose. To investigate whether the systematic use of a higher dose of IM could lead to better results, 216 patients with Ph(+) CML at high risk (HR) according to the Sokal index were randomly assigned to receive IM 800 mg or 400 mg daily, as front-line therapy, for at least 1 year. The CCgR rate at 1 year was 64% and 58% for the high-dose arm and for the standard-dose arm, respectively (P = .435). No differences were detectable in the CgR at 3 and 6 months, in the molecular response rate at any time, as well as in the rate of other events. Twenty-four (94%) of 25 patients who could tolerate the full 800-mg dose achieved a CCgR, and only 4 (23%) of 17 patients who could tolerate less than 350 mg achieved a CCgR. This study does not support the extensive use of high-dose IM (800 mg daily) front-line in all CML HR patients. This trial was registered at www.clinicaltrials.gov as #NCT00514488.
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323
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Radich JP. Optimizing timing of secondary tyrosine kinase therapy in chronic myeloid leukemia. ACTA ACUST UNITED AC 2009; 8 Suppl 3:S89-94. [PMID: 19254886 DOI: 10.3816/clm.2008.s.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The tyrosine kinase inhibitor (TKI) imatinb has radically changed the treatment of chronic myeloid leukemia (CML). Most patients treated in chronic phase can be expected to achieve a complete cytogenetic remission (CCyR). However, primary imatinib therapy fails in a number of patients initially, or relapse occurs later after a good cytogenetic response. Treatment of accelerated phase and blast crisis yields disappointing results and is rarely associated with long-term disease control. Imatinib failures can now be potentially salvaged with new TKIs or, if a donor exists, by a hematopoetic stem cell transplantation. Given these multiple effective treatment options, tight monitoring of cytogenetic and molecular response is essential in deciding when imatinib therapy should be abandoned for alternative therapy. This review will define the types of tests used to monitor the disease, provide clinically relevant endpoints, and outline guidelines for monitoring patients with CML on imatinib therapy.
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Affiliation(s)
- Jerald P Radich
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
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324
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Extending the duration of response in chronic myelogenous leukemia: targeted therapy with sequential tyrosine kinase inhibitors. Oncol Rev 2009. [DOI: 10.1007/s12156-009-0004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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325
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Abstract
Chronic myeloid leukemia (CML) has been regarded as the paradigmatic example of a malignancy defined by a unique molecular event, the BCR-ABL1 oncogene. Decades of research zeroing in on the role of BCR-ABL1 kinase in the pathogenesis of CML have culminated in the development of highly efficacious therapeutics that, like imatinib mesylate, target the oncogenic kinase activity of BCR-ABL1. In recent years, most research efforts in CML have been devoted to developing novel tyrosine kinase inhibitors (TKIs) as well as to elucidating the mechanisms of resistance to imatinib and other TKIs. Nonetheless, primordial aspects of the pathogenesis of CML, such as the mechanisms responsible for the transition from chronic phase to blast crisis, the causes of genomic instability and faulty DNA repair, the phenomenon of stem cell quiescence, the role of tumor suppressors in TKI resistance and CML progression, or the cross-talk between BCR-ABL1 and other oncogenic signaling pathways, still remain poorly understood. Herein, we synthesize the most relevant and current knowledge on such areas of the pathogenesis of CML.
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326
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Tamascar I, Ramanarayanan J. Targeted treatment of chronic myeloid leukemia: role of imatinib. Onco Targets Ther 2009; 2:63-71. [PMID: 20616895 PMCID: PMC2886320 DOI: 10.2147/ott.s3993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by clonal expansion of pleuripotent hematopoetic stem cells. The incidence of CML is 1 to 2 cases per 100,000 people per year; in the Western Hemisphere, CML accounts for 15% of leukemias in adults. Discovery of the specific karyotypic abnormality of the Philadelphia (Ph) chromosome in the pathogenesis of CML has led to a better understanding of the disease and hence to an advancement of targeted therapeutics. Availability of imatinib as an accepted targeted therapy in newly diagnosed patients has changed the treatment paradigm in CML. The majority of CML patients in chronic phase achieve excellent and durable responses with standard-dose imatinib. Mechanisms of primary and secondary resistance to imatinib in CML have been extensively studied and newer tyrosine kinase inhibitors are now being evaluated for clinical use. It is important that at any time the CML treatment and response remain optimal and thus patients on imatinib require continuous monitoring for early detection of resistance. This review will discuss the treatment and guidelines for monitoring CML patients in the imatinib era.
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Affiliation(s)
- Ila Tamascar
- Department of Medical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY, USA
| | - Jeyanthi Ramanarayanan
- Department of Medical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY, USA
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327
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Singh N, Kumar L, Meena R, Velpandian T. Drug monitoring of imatinib levels in patients undergoing therapy for chronic myeloid leukaemia: comparing plasma levels of responders and non-responders. Eur J Clin Pharmacol 2009; 65:545-9. [PMID: 19214491 DOI: 10.1007/s00228-009-0621-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 01/15/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE Imatinib mesylate is used as first line therapy in the treatment of chronic myeloid leukaemia. This study was designed to study the correlation of plasma levels of imatinib with response to the therapy. METHODS A total of 40 chronic myeloid leukaemia patients in the chronic phase of the disease were recruited and placed into two groups of 20 patients: imatinib responders and imatinib non-responders, respectively. Each blood sample was taken 24 h after and immediately prior to taking a 400 mg oral dose of imatinib. Drug levels were detected by high-performance liquid chromatography. RESULTS The mean plasma imatinib levels in the imatinib non-responders were significantly lower than those in the imatinib responders (0.70 vs. 2.34 microM, respectively; p = 0.002). CONCLUSIONS Plasma levels of imatinib were correlated with response to the therapy, so routine monitoring of the therapeutic levels of the drug should be carried out specifically in treatment-resistant cases for determining dose escalation.
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Affiliation(s)
- N Singh
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India
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328
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Jabbour E, Cortes JE, Kantarjian HM. Suboptimal response to or failure of imatinib treatment for chronic myeloid leukemia: what is the optimal strategy? Mayo Clin Proc 2009; 84:161-9. [PMID: 19181650 PMCID: PMC2664587 DOI: 10.4065/84.2.161] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Treatment responses to imatinib vary among patients with chronic myeloid leukemia (CML), and definitions of treatment failure and suboptimal response have been published. This article discusses monitoring and treatment of patients with CML after failure of or suboptimal response to imatinib therapy. We reviewed articles listed on PubMed from January 1, 2002, to July 31, 2008, and abstracts from the 2007 Annual Meeting of the American Society of Hematology. Search terms used were chronic myeloid/myelogenous leukemia, imatinib, and BCR-ABL. To enable early recognition of suboptimal responses, patients should be frequently monitored according to published guidelines, including cytogenetic analysis every 6 months until a complete response is achieved and molecular monitoring every 3 months from the start of therapy or monthly if an increasing BCR-ABL1 transcript level is detected. Mutational analysis of BCR-ABL1 may assist with treatment selection. A recent survey suggests that a notable proportion of physicians do not follow treatment guidelines and that broader communication is required. Recent recommendations state that, in patients whose response to imatinib at 400 mg/d is suboptimal, the dose should be increased, whereas alternative therapies, such as dasatinib, nilotinib, and allogeneic stem cell transplant (in eligible patients), and imatinib dose escalation should be considered after imatinib failure. However, clinical data are lacking to confirm this sequence of treatments, and introducing alternative therapies at an earlier stage of treatment, for example, after a suboptimal response, may produce better long-term outcomes in a higher proportion of patients. Patient and disease characteristics should be carefully considered to optimize treatment strategy for CML.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas, M. D. Anderson Cancer Center, Houston, 77030, USA.
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329
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Jabbour E, Cortes JE, Kantarjian HM. Suboptimal response to or failure of imatinib treatment for chronic myeloid leukemia: what is the optimal strategy? Mayo Clin Proc 2009; 84:161-9. [PMID: 19181650 PMCID: PMC2664587 DOI: 10.1016/s0025-6196(11)60824-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment responses to imatinib vary among patients with chronic myeloid leukemia (CML), and definitions of treatment failure and suboptimal response have been published. This article discusses monitoring and treatment of patients with CML after failure of or suboptimal response to imatinib therapy. We reviewed articles listed on PubMed from January 1, 2002, to July 31, 2008, and abstracts from the 2007 Annual Meeting of the American Society of Hematology. Search terms used were chronic myeloid/myelogenous leukemia, imatinib, and BCR-ABL. To enable early recognition of suboptimal responses, patients should be frequently monitored according to published guidelines, including cytogenetic analysis every 6 months until a complete response is achieved and molecular monitoring every 3 months from the start of therapy or monthly if an increasing BCR-ABL1 transcript level is detected. Mutational analysis of BCR-ABL1 may assist with treatment selection. A recent survey suggests that a notable proportion of physicians do not follow treatment guidelines and that broader communication is required. Recent recommendations state that, in patients whose response to imatinib at 400 mg/d is suboptimal, the dose should be increased, whereas alternative therapies, such as dasatinib, nilotinib, and allogeneic stem cell transplant (in eligible patients), and imatinib dose escalation should be considered after imatinib failure. However, clinical data are lacking to confirm this sequence of treatments, and introducing alternative therapies at an earlier stage of treatment, for example, after a suboptimal response, may produce better long-term outcomes in a higher proportion of patients. Patient and disease characteristics should be carefully considered to optimize treatment strategy for CML.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas, M. D. Anderson Cancer Center, Houston, 77030, USA.
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330
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Chu SH, Small D. Mechanisms of resistance to FLT3 inhibitors. Drug Resist Updat 2009; 12:8-16. [PMID: 19162530 PMCID: PMC4891941 DOI: 10.1016/j.drup.2008.12.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 12/02/2008] [Indexed: 11/21/2022]
Abstract
The success of the small molecule tyrosine kinase receptor inhibitor (TKI) imatinib mesylate (Gleevec) in the treatment of chronic myeloid leukemia (CML) constitutes an eminent paradigm shift advocating the rational design of cancer therapeutics specifically targeting the transformation events that drive tumorigenicity. In acute myeloid leukemias (AMLs), the most frequent identified transforming events are activating mutations in the FLT3 receptor tyrosine kinase that constitutively activate survival and proliferation pathways. FLT3 TKIs that are in various phases of clinical trials are showing some initial promise. However, primary and secondary acquired resistance stands to severely compromise long-term and durable efficacy of these inhibitors as a therapeutic strategy. Here, we discuss the mechanisms of resistance to FLT3 inhibitors and possible strategies to overcome resistance through closer examination of the events of leukemogenesis and design of combination therapy.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacokinetics
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols
- Cell Proliferation/drug effects
- Cell Survival/drug effects
- Drug Resistance, Neoplasm/genetics
- Gene Expression Regulation, Leukemic
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/enzymology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/enzymology
- Protein Kinase Inhibitors/pharmacokinetics
- Protein Kinase Inhibitors/therapeutic use
- fms-Like Tyrosine Kinase 3/antagonists & inhibitors
- fms-Like Tyrosine Kinase 3/genetics
- fms-Like Tyrosine Kinase 3/metabolism
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Affiliation(s)
- S. Haihua Chu
- Department of Oncology, Johns Hopkins University School of Medicine, CRB1-251, 1650 Orleans St., Baltimore, MD 21231-1000, United States
- Cellular and Molecular Medicine Program, Johns Hopkins University School of Medicine, CRB1-251, 1650 Orleans St., Baltimore, MD 21231-1000, United States
| | - Donald Small
- Department of Oncology, Johns Hopkins University School of Medicine, CRB1-251, 1650 Orleans St., Baltimore, MD 21231-1000, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, CRB1-251, 1650 Orleans St., Baltimore, MD 21231-1000, United States
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331
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Volpe G, Panuzzo C, Ulisciani S, Cilloni D. Imatinib resistance in CML. Cancer Lett 2009; 274:1-9. [DOI: 10.1016/j.canlet.2008.06.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 03/20/2008] [Accepted: 06/02/2008] [Indexed: 12/25/2022]
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332
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Breccia M, Frustaci AM, Cannella L, Soverini S, Stefanizzi C, Federico V, Grammatico S, Santopietro M, Alimena G. Sequential development of mutant clones in an imatinib resistant chronic myeloid leukaemia patient following sequential treatment with multiple tyrosine kinase inhibitors: an emerging problem? Cancer Chemother Pharmacol 2009; 64:195-7. [DOI: 10.1007/s00280-008-0905-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 12/12/2008] [Indexed: 10/21/2022]
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333
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Huang HM, Liu JC. c-Jun blocks cell differentiation but not growth inhibition or apoptosis of chronic myelogenous leukemia cells induced by STI571 and by histone deacetylase inhibitors. J Cell Physiol 2009; 218:568-74. [PMID: 19006173 DOI: 10.1002/jcp.21627] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The constitutively active Bcr-Abl tyrosine kinase plays a crucial role in chronic myelogenous leukemia (CML) pathogenesis. The Bcr-Abl protein induces the upregulation of proto-oncogene c-Jun, which is involved in Bcr-Abl transforming activity in Bcr-Abl positive cells. Recent studies reported that c-Jun inhibited hemoglobin synthesis in human CML cell line K562. However, c-Jun also plays a critical role in cell proliferation and apoptosis. In this study, we investigated the physiological roles of c-Jun in cell proliferation, apoptosis and erythroid differentiation of K562 cells. Firstly, we generated K562 cell lines stably overexpressing c-Jun. These clones have the same proliferation rate as the parental cell line in general culture medium. Endogenous c-Jun expression was analyzed to determine the effective concentration of STI571 for inhibiting Bcr-Abl signaling. Western blots show that STI571 inhibited c-Jun expression in a dose-dependent manner, reaching a maximum inhibition at 1 microM. STI571 could inhibit c-Jun expression in K562 cells, but not in c-Jun-overexpression cells. c-Jun did not alter growth inhibition and apoptotic induction by STI571 treatment, but inhibited STI571-induced erythroid differentiation. Moreover, c-Jun did not alter growth inhibition and apoptotic induction by histone deacetylase (HDAC) inhibitors (apicidin, sodium butyrate, and MS275) treatment, but inhibited HDAC inhibitors-induced erythroid differentiation. These results suggest that c-Jun may modulate anticancer drugs-induced cell differentiation but not growth inhibition and apoptosis in CML cells.
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Affiliation(s)
- Huei-Mei Huang
- Graduate Institute of Medical Sciences, Taipei Medical University, Taipei, Taiwan.
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334
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Abstract
AbstractThe remarkable progress made in the treatment of chronic myeloid leukemia (CML) over the past decade has been accompanied by steady improvements in our capacity to accurately and sensitively monitor response to therapy. After the initial target of therapy, complete cytogenetic response (CCR), is achieved, peripheral blood BCR-ABL transcript levels measured by real-time quantitative reverse transcriptase PCR (RQ-PCR) define the subsequent response targets, major and complete molecular response (MMR and CMR). The majority of patients on first-line imatinib therapy achieve a “safe haven” defined as a confirmed MMR, but 20% to 30% stop imatinib due to intolerance and/or resistance. Many imatinib-resistant patients can be effectively treated with second generation tyrosine kinase inhibitors (TKIs), but the actual drug selected should be based on the resistance profile of each inhibitor, in addition to issues of tolerance and disease phase. The main purpose of monitoring response with cytogenetics and RQ-PCR is to identify patients likely to achieve better long-term outcome if they are switched early to second-line therapy, either another TKI or an allograft. Mutation screening is most valuable in cases of loss of response to imatinib or a second-line TKI, but there are other settings where a high yield of mutations may justify regular mutation screening.
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335
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Bixby D, Talpaz M. Mechanisms of resistance to tyrosine kinase inhibitors in chronic myeloid leukemia and recent therapeutic strategies to overcome resistance. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2009; 2009:461-476. [PMID: 20008232 DOI: 10.1182/asheducation-2009.1.461] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Given its relative rarity, it may at first seem surprising that chronic myeloid leukemia (CML) has garnered so much attention over the last decade. Yet, the advances in molecular pathogenesis that have been derived from studying this leukemia have clearly benefited all of oncology. Moreover, the strides in drug design and development that have also ensued around CML have given rise to what others have called a molecular revolution in cancer therapy. While a majority of patients with chronic phase CML (CP-CML) have an excellent durable response to imatinib (Gleevec, Novartis, Basel, Switzerland), a clear minority will unfortunately have signs of primary or secondary resistance to therapy. Significant efforts geared toward understanding the molecular mechanisms of imatinib resistance have yielded valuable insights into the biology of drug trafficking into and out of cells, epigenetic control of cellular processes, alterations in enzymatic structures, and the rational structural-based design of small molecule enzyme inhibitors. This review will describe the efforts at understanding the pathogenesis of imatinib resistance and the molecular rationale for the development of second- and now third-generation therapies for patients with CML.
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MESH Headings
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/pharmacokinetics
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Benzamides
- Biological Transport/drug effects
- Dose-Response Relationship, Drug
- Drug Delivery Systems
- Drug Design
- Drug Resistance, Neoplasm/drug effects
- Drugs, Investigational/pharmacology
- Drugs, Investigational/therapeutic use
- Epigenesis, Genetic
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/physiology
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Neoplasm Proteins/antagonists & inhibitors
- Neoplasm Proteins/genetics
- Neoplasm Proteins/physiology
- Piperazines/administration & dosage
- Piperazines/pharmacokinetics
- Piperazines/pharmacology
- Piperazines/therapeutic use
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/classification
- Protein Kinase Inhibitors/pharmacokinetics
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Pyrimidines/administration & dosage
- Pyrimidines/pharmacokinetics
- Pyrimidines/pharmacology
- Pyrimidines/therapeutic use
- Salvage Therapy
- Signal Transduction/drug effects
- Signal Transduction/genetics
- Signal Transduction/physiology
- Structure-Activity Relationship
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Affiliation(s)
- Dale Bixby
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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336
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Jones D, Kamel-Reid S, Bahler D, Dong H, Elenitoba-Johnson K, Press R, Quigley N, Rothberg P, Sabath D, Viswanatha D, Weck K, Zehnder J. Laboratory practice guidelines for detecting and reporting BCR-ABL drug resistance mutations in chronic myelogenous leukemia and acute lymphoblastic leukemia: a report of the Association for Molecular Pathology. J Mol Diagn 2008; 11:4-11. [PMID: 19095773 DOI: 10.2353/jmoldx.2009.080095] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The BCR-ABL tyrosine kinase produced by the t(9;22)(q34;q11) translocation, also known as the Philadelphia chromosome, is the initiating event in chronic myeloid leukemia (CML) and Ph+ acute lymphoblastic leukemia (ALL). Targeting of BCR-ABL with tyrosine kinase inhibitors (TKIs) has resulted in rapid clinical responses in the vast majority of patients with CML and Philadelphia chromosome+ ALL. However, long-term use of TKIs occasionally results in emergence of therapy resistance, in part through the selection of clones with mutations in the BCR-ABL kinase domain. We present here an overview of the current practice in monitoring for such mutations, including the methods used, the clinical and laboratory criteria for triggering mutational analysis, and the guidelines for reporting BCR-ABL mutations. We also present a proposal for a public database for correlating mutational status with in vitro and in vivo responses to different TKIs to aid in the interpretation of mutation studies.
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Affiliation(s)
- Dan Jones
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; University of Texas M. D. Anderson Cancer Center, Houston, Texas.
| | - Suzanne Kamel-Reid
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; The University Health Network, Toronto, Canada
| | - David Bahler
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; ARUP Laboratories, Salt Lake City, Utah
| | - Henry Dong
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; Genzyme Genetics, New York City, New York
| | - Kojo Elenitoba-Johnson
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; University of Michigan Medical School, Ann Arbor, Michigan
| | - Richard Press
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; Oregon Health & Science University, Portland, Oregon
| | - Neil Quigley
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; Molecular Pathology Laboratory Network, Inc., Maryville, Tennessee
| | - Paul Rothberg
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; University of Rochester Medical Center, Rochester, New York
| | - Dan Sabath
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; University of Washington, Seattle, Washington
| | - David Viswanatha
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; Mayo Clinic, Rochester, Minnesota
| | - Karen Weck
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; University of North Carolina, Chapel Hill, North Carolina
| | - James Zehnder
- ABL Mutation Working Group of the Association for Molecular Pathology, Clinical Practice Committee, Houston, Texas; Stanford University, Stanford, California
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337
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Recent advances in the treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia. Int J Hematol 2008; 89:3-13. [PMID: 19093166 DOI: 10.1007/s12185-008-0223-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 10/01/2008] [Accepted: 11/07/2008] [Indexed: 01/01/2023]
Abstract
The advent of imatinib, a selective inhibitor of the ABL tyrosine kinase, has revolutionized the treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). Combined with chemotherapy, imatinib exerts remarkable efficacy in patients with newly diagnosed disease with a complete remission (CR) rate of 95% and a survival rate of 55% at 3 years. Profound eradication of leukemia cells not only provides patients with a better chance for receiving allogeneic hematopoietic stem cell transplantation during first CR but also contributes to durable CR even without transplantation. Despite such improvement, however, relapse does occur, mainly owing to acquisition of resistance. Growing comprehension of the molecular mechanisms of resistance to imatinib has led to the development of novel BCR-ABL inhibitors that yield higher affinity for BCR-ABL and/or potent inhibitory activity against other target molecules such as SRC family kinases. The second-generation ABL kinase inhibitors, namely dasatinib and nilotinib, are already showing clinical activity in patients with imatinib-resistant Ph+ ALL, and other novel agents are undergoing preclinical and early clinical evaluation. Further improvement in treatment results will be achieved by identifying each patient's disease profile based on information obtained before and during treatment and by optimizing subsequent treatment accordingly.
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338
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Characteristics and outcome of chronic myeloid leukemia patients with F317L BCR-ABL kinase domain mutation after therapy with tyrosine kinase inhibitors. Blood 2008; 112:4839-42. [PMID: 18818391 PMCID: PMC4186640 DOI: 10.1182/blood-2008-04-149948] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Mutations in codon 317 after treatment with imatinib and dasatinib have been reported. We reviewed patients with chronic myeloid leukemia and mutations after tyrosine kinase inhibitor (TKI) therapy. F317L was detected in 20, including 12/99 (12%) with mutation after imatinib failure, and 8/16 (50%) after dasatinib (P = .001). Median follow-up from mutation detection was 25 months. At the time of F317L, 8 patients were in chronic phase (CP), 6 in accelerated phase, and 6 in blast phase. There was no difference in characteristics between patients with or without F317L mutations, or with no mutations. A complete cytogenetic response was achieved in 3 of 6 patients treated with nilotinib, 2 of 2 with imatinib, and 0 of 3 with dasatinib. Survival of patients with F317L was similar to those with other mutations (P = .45). Patients in CP had better outcome, with a 2-year survival of 75%. F317L mutation is resistant to dasatinib but sensitive to other TKIs. The prognosis is dependent mostly on the disease stage.
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339
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Lee TS, Ma W, Zhang X, Giles F, Cortes J, Kantarjian H, Albitar M. BCR-ABL alternative splicing as a common mechanism for imatinib resistance: evidence from molecular dynamics simulations. Mol Cancer Ther 2008; 7:3834-41. [PMID: 19056677 DOI: 10.1158/1535-7163.mct-08-0482] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rare cases of chronic myelogenous leukemia (CML) express high levels of alternatively spliced BCR-ABL mRNA with a 35-bp insertion (35INS) between ABL kinase domain exons 8 and 9. This insertion results in a frameshift leading to the addition of 10 residues and truncation of 653 residues due to early termination. Sensitive PCR-based testing showed that 32 of 52 (62%) imatinib-resistant CML patients in chronic phase and 8 of 38 (21%) in accelerated or blast crisis expressed varying levels of the alternatively spliced BCR-ABL mRNA. A three-dimensional structural model of the 35INS ABL kinase domain complexed with imatinib was built using homology modeling, followed by molecular dynamics simulations. Simulation results showed that the new residues cause a significant global conformational change, altering imatinib binding in a way similar to that of the T315I mutation and, therefore, providing resistance to imatinib that depends on the level of expression.
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Affiliation(s)
- Tai-Sung Lee
- Consortium for Bioinformatics and Computational Biology and Department of Chemistry, University of Minnesota, 207 Pleasant Street Southeast, Minneapolis, MN 55455, USA.
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340
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BCR-ABL1-positive CML and BCR-ABL1-negative chronic myeloproliferative disorders: some common and contrasting features. Leukemia 2008; 22:1975-89. [PMID: 19002192 DOI: 10.1038/leu.2008.231] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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341
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Abstract
Chronic myelogenous leukemia (CML) is defined by the presence of the constitutively active tyrosine kinase breakpoint cluster region/Abelson (Bcr-Abl), which activates numerous signal transduction pathways leading to uncontrolled cell proliferation. The development of the Bcr-Abl-targeted imatinib represents a paradigm shift in the treatment of CML, because treatment with imatinib resulted in significantly better patient outcome, response rates, and overall survival compared with previous standards. Despite this advance, not all patients benefit from imatinib because of resistance and intolerance. Resistance to imatinib can develop from a number of mechanisms that can be defined as Bcr-Abl-dependent (e.g., most commonly resulting from point mutations in the Abl kinase domain) and Bcr-Abl-independent mechanisms (including the constitutive activation of downstream signaling molecules, e.g., Src family kinases), which could result in the activation of the pathway regardless of Bcr-Abl inhibition. Clearly, new treatment approaches are required for patients resistant to or intolerant of imatinib, which can be dose escalated in patients who demonstrate resistance. This does not result in long-term responses. Hematopoietic stem cell transplantation is limited by the availability of matched donors and the potential for morbidity. Dasatinib, a dual Bcr-Abl/Src kinase inhibitor, has shown efficacy against all imatinib-resistant Bcr-Abl mutations except for T315I. A large trial program showed that dasatinib is effective in patients previously exposed to imatinib and has a manageable safety profile in all phases of CML and Philadelphia chromosome-positive acute lymphoblastic leukemia, resulting in its approval. Nilotinib, an analogue of imatinib, also has demonstrated activity in a similar patient population. These agents and less clinically advanced strategies are discussed in this review.
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Affiliation(s)
- Pablo Ramirez
- Siteman Cancer Center, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8007, St. Louis, Missouri 63110, USA.
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342
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Khorashad JS, de Lavallade H, Apperley JF, Milojkovic D, Reid AG, Bua M, Szydlo R, Olavarria E, Kaeda J, Goldman JM, Marin D. Finding of kinase domain mutations in patients with chronic phase chronic myeloid leukemia responding to imatinib may identify those at high risk of disease progression. J Clin Oncol 2008; 26:4806-13. [PMID: 18645191 PMCID: PMC10466446 DOI: 10.1200/jco.2008.16.9953] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 05/27/2008] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Kinase domain (KD) mutations in the BCR-ABL gene are associated with resistance to imatinib in chronic myeloid leukemia (CML) but their incidence and prognostic significance in chronic phase (CP) patients without resistance are unclear. PATIENTS AND METHODS We analyzed outcome for 319 patients with CML-CP who were treated with imatinib; 171 were in early CP (ECP) and 148 were in late CP (LCP). Patients were screened routinely for mutations using direct sequencing regardless of response status. The 5-year cumulative incidence of mutations was 6.6% for ECP and 17% for LCP patients. RESULTS Of the 319 patients, 214 (67%) achieved complete cytogenetic responses (CCyR). The identification of a mutation without other evidence of imatinib resistance was highly predictive for loss of CCyR (RR, 3.8; P = .005) and for progression to advanced phase (RR, 2.3; P = .01), though the intervals from first identification to loss of CCyR and disease progression were relatively long (median, 21 and 16 months, respectively). Mutations in the P-loop (excluding residue 244) were associated with a higher risk of progression than mutations elsewhere. CONCLUSION We conclude that routine mutation screening of patients who appear to be responding to imatinib may identify those at high risk of disease progression.
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Affiliation(s)
- Jamshid S. Khorashad
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Hugues de Lavallade
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Jane F. Apperley
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Dragana Milojkovic
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Alistair G. Reid
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Marco Bua
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Richard Szydlo
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Eduardo Olavarria
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Jaspal Kaeda
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - John M. Goldman
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - David Marin
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
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343
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Cho EH, Kang SK, Kim SY. Supplemental results of the detection of splicing variant with c-ABL exon 7 deletion by direct sequencing Comment on "A recurrent splicing variant without c-ABL Exon 7 in Imatinib-resistant patients" by Curvo et al. [Leuk. Res.]. Leuk Res 2008; 33:505-6. [PMID: 18848355 DOI: 10.1016/j.leukres.2008.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 08/15/2008] [Accepted: 08/24/2008] [Indexed: 10/21/2022]
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344
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Hazarika M, Jiang X, Liu Q, Lee SL, Ramchandani R, Garnett C, Orr MS, Sridhara R, Booth B, Leighton JK, Timmer W, Harapanhalli R, Dagher R, Justice R, Pazdur R. Tasigna for chronic and accelerated phase Philadelphia chromosome--positive chronic myelogenous leukemia resistant to or intolerant of imatinib. Clin Cancer Res 2008; 14:5325-31. [PMID: 18765523 DOI: 10.1158/1078-0432.ccr-08-0308] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE This Food and Drug Administration (FDA) approval report describes the data and analyses leading to the approval by the FDA of nilotinib (Tasigna, AMN-107; Novartis Pharmaceuticals Corporation), an inhibitor of Bcr-Abl tyrosine kinase, for the treatment of chronic-phase (CP) and accelerated-phase (AP) chronic myelogenous leukemia (CML) resistant to or intolerant of imatinib. EXPERIMENTAL DESIGN The FDA approval of the efficacy and safety of nilotinib was based on the results of an ongoing single-arm, open-label, phase 2 clinical trial. The primary end point for CML-CP was unconfirmed major cytogenetic response. The efficacy end point for CML-AP was confirmed hematologic response. RESULTS The major cytogenetic response rate in 232 evaluable CP patients was 40% (95% confidence interval, 33%, 46%). The hematologic response rate in 105 evaluable AP patients was 26% (95% confidence interval, 18%, 35%). The median duration of response has not been reached for both CML-CP and CML-AP responding patients. In CML-CP patients, the common serious drug-related adverse reactions were thrombocytopenia and neutropenia. In CML-AP patients, the common serious drug-related adverse reactions were thrombocytopenia, neutropenia, pneumonia, febrile neutropenia, leukopenia, intracranial hemorrhage, elevated lipase, and pyrexia. Nilotinib prolongs the QT interval and sudden deaths have been reported; these risks and appropriate risk minimization strategies are described in a boxed warning on the labeling. CONCLUSIONS On October 29, 2007, the U.S. FDA granted accelerated approval to nilotinib (Tasigna) for use in the treatment of CP and AP Philadelphia chromosome positive CML in adult patients resistant to or intolerant of prior therapy that included imatinib.
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Affiliation(s)
- Maitreyee Hazarika
- Office of Oncology Drug Products, Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland 20993, USA
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345
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Kantarjian H, O'Brien S, Cortes J, Wierda W, Faderl S, Garcia-Manero G, Issa JP, Estey E, Keating M, Freireich EJ. Therapeutic advances in leukemia and myelodysplastic syndrome over the past 40 years. Cancer 2008; 113:1933-52. [PMID: 18798533 PMCID: PMC4392892 DOI: 10.1002/cncr.23655] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Major therapeutic progress has been accomplished in leukemia and myelodysplastic syndrome (MDS) over the past 40 years, which may not be fully appreciated by the larger medical community. The objective of this review was to briefly highlight the treatment breakthroughs in leukemia and MDS. Therapeutic progress happened through better understanding of disease pathophysiologies and rational development of targeted agents, like imatinib mesylate in chronic myeloid leukemia (CML), and through astute, empirical discoveries in the clinic, like all-trans retinoic acid and arsenic trioxide in acute promyelocytic leukemia (APL) and chlorodeoxyadenosine in hairy cell leukemia (HCL). Today, the 5- to 10-year survival rates in patients with APL and HCL exceed 80%. In patients with CML, imatinib therapy has been associated with estimated 5- to 7-year survival rates from 85% to 90%. In patients with adult acute lymphocytic leukemia, modern intensive regimens have improved the 5-year survival rates from 20% up to 40%. In patients with chronic lymphocytic leukemia, chemoimmunotherapy recently produced high rates of quality responses and improved long-term outcome. In younger patients with acute myeloid leukemia (AML), the 5-year survival rates range from 40% to 50%, although elderly AML remains a therapeutic challenge. In patients with MDS, it was recently demonstrated that epigenetic therapy with hypomethylating agents improved survival. Much therapeutic progress has been witnessed in leukemia and MDS, and much more is expected to occur soon.
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MESH Headings
- Humans
- Leukemia/mortality
- Leukemia/therapy
- Leukemia, Hairy Cell/mortality
- Leukemia, Hairy Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Myelodysplastic Syndromes/mortality
- Myelodysplastic Syndromes/therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
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Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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346
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Cang S, Liu D. P-loop mutations and novel therapeutic approaches for imatinib failures in chronic myeloid leukemia. J Hematol Oncol 2008; 1:15. [PMID: 18828913 PMCID: PMC2567340 DOI: 10.1186/1756-8722-1-15] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 10/01/2008] [Indexed: 11/10/2022] Open
Abstract
Imatinib was the first BCR-ABL-targeted agent approved for the treatment of patients with chronic myeloid leukemia (CML) and confers significant benefit for most patients; however, a substantial number of patients are either initially refractory or develop resistance. Point mutations within the ABL kinase domain of the BCR-ABL fusion protein are a major underlying cause of resistance. Of the known imatinib-resistant mutations, the most frequently occurring involve the ATP-binding loop (P-loop). In vitro evidence has suggested that these mutations are more oncogenic with respect to other mutations and wild type BCR-ABL. Dasatinib and nilotinib have been approved for second-line treatment of patients with CML who demonstrate resistance (or intolerance) to imatinib. Both agents have marked activity in patients resistant to imatinib; however, they have differential activity against certain mutations, including those of the P-loop. Data from clinical trials suggest that dasatinib may be more effective vs. nilotinib for treating patients harboring P-loop mutations. Other mutations that are differentially sensitive to the second-line tyrosine kinase inhibitors (TKIs) include F317L and F359I/V, which are more sensitive to nilotinib and dasatinib, respectively. P-loop status in patients with CML and the potency of TKIs against P-loop mutations are key determinants for prognosis and response to treatment. This communication reviews the clinical importance of P-loop mutations and the efficacy of the currently available TKIs against them.
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Affiliation(s)
- Shundong Cang
- Division of Hematology/Oncology, New York Medical College, Valhalla, NY 10595, USA.
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347
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Rodrigues MS, Reddy MM, Sattler M. Cell cycle regulation by oncogenic tyrosine kinases in myeloid neoplasias: from molecular redox mechanisms to health implications. Antioxid Redox Signal 2008; 10:1813-48. [PMID: 18593226 DOI: 10.1089/ars.2008.2071] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Neoplastic expansion of myeloid cells is associated with specific genetic changes that lead to chronic activation of signaling pathways, as well as altered metabolism. It has become increasingly evident that transformation relies on the interdependency of both events. Among the various genetic changes, the oncogenic BCR-ABL tyrosine kinase in patients with Philadelphia chromosome positive chronic myeloid leukemia (CML) has been a focus of extensive research. Transformation by this oncogene is associated with elevated levels of intracellular reactive oxygen species (ROS). ROS have been implicated in processes that promote viability, cell growth, and regulation of other biological functions such as migration of cells or gene expression. Currently, the BCR-ABL inhibitor imatinib mesylate (Gleevec) is being used as a first-line therapy for the treatment of CML. However, BCR-ABL transformation is associated with genomic instability, and disease progression or resistance to imatinib can occur. Imatinib resistance is not known to cause or significantly alter signaling requirements in transformed cells. Elevated ROS are crucial for transformation, making them an ideal additional target for therapeutic intervention. The underlying mechanisms leading to elevated oxidative stress are reviewed, and signaling mechanisms that may serve as novel targeted approaches to overcome ROS-dependent cell growth are discussed.
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Affiliation(s)
- Margret S Rodrigues
- Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts 02115, USA
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348
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Jones D, Thomas D, Yin CC, O'Brien S, Cortes JE, Jabbour E, Breeden M, Giles FJ, Zhao W, Kantarjian HM. Kinase domain point mutations in Philadelphia chromosome-positive acute lymphoblastic leukemia emerge after therapy with BCR-ABL kinase inhibitors. Cancer 2008; 113:985-94. [PMID: 18615627 DOI: 10.1002/cncr.23666] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND BCR-ABL kinase domain (KD) mutations are detected in approximately 45% of patients with imatinib-resistant chronic myeloid leukemia. Patterns of KD mutations in Philadelphia chromosome (Ph)-positive acute lympho- blastic leukemia (ALL) are less well studied. METHODS The authors assessed KD mutations in patients with recurrent Ph-positive ALL after treatments that included 1 or more kinase inhibitors (n = 24 patients) or no prior kinase inhibitor (KI) therapy (n = 12 patients). RESULTS ABL KD mutations were detected by direct sequencing in 15 of 17 patients (88%) who had recurrent Ph-positive ALL and received prior imatinib (n = 16) or dasatinib (n = 1) treatment and in 6 of 7 patients (86%) who had resistant/recurrent tumors treated with >or=2 KIs compared with 0 of 12 patients with recurrent Ph-positive ALL who never received KIs. A restricted set of mutations was observed, mostly Y253H and T315I, and were detected on average 10 months after KI initiation, and mutations were not detected in the initial tumor samples before KI therapy in 12 patients who were assessed. Using a more sensitive pyrosequencing method, mutations were not detected at codons 315 and 253 in the diagnostic samples from those 12 patients or in 30 patients with Ph-positive ALL who never developed recurrent disease. CONCLUSIONS ABL KD mutations, especially at codons 315 and 253, emerged at the time of disease recurrence in the vast majority of patients who had Ph-positive ALL and received maintenance KI therapy. Thus, the authors concluded that ongoing KI exposure may alter the patterns of recurrence and favor the outgrowth of clones with KI-resistant mutations.
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Affiliation(s)
- Dan Jones
- Department of Hematopathology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Impact of early dose intensity on cytogenetic and molecular responses in chronic- phase CML patients receiving 600 mg/day of imatinib as initial therapy. Blood 2008; 112:3965-73. [PMID: 18768781 DOI: 10.1182/blood-2008-06-161737] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a trial in 103 patients with newly diagnosed chronic phase chronic myeloid leukemia (CP-CML) using imatinib 600 mg/day, with dose escalation to 800 mg/day for suboptimal response. The estimated cumulative incidences of complete cytogenetic response (CCR) by 12 and 24 months were 88% and 90%, and major molecular responses (MMRs) were 47% and 73%. In patients who maintained a daily average of 600 mg of imatinib for the first 6 months (n = 60), MMR rates by 12 and 24 months were 55% and 77% compared with 32% and 53% in patients averaging less than 600 mg (P = .037 and .016, respectively). Dose escalation was indicated for 17 patients before 12 months for failure to achieve, or maintain, major cytogenetic response at 6 months or CCR at 9 months but was only possible in 8 patients (47%). Dose escalation was indicated for 73 patients after 12 months because their BCR-ABL level remained more than 0.01% (international scale) and was possible in 45 of 73 (62%). Superior responses achieved in patients able to tolerate imatinib at 600 mg suggests that early dose intensity may be critical to optimize response in CP-CML. The trial was registered at www.ANZCTR.org.au as #ACTRN12607000614493.
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350
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Ko J, Patel N, Ikawa T, Kawamoto H, Frank O, Rivera RR, Van Etten RA, Murre C. Suppression of E-protein activity interferes with the development of BCR-ABL-mediated myeloproliferative disease. Proc Natl Acad Sci U S A 2008; 105:12967-72. [PMID: 18725623 PMCID: PMC2529058 DOI: 10.1073/pnas.0805073105] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Indexed: 12/21/2022] Open
Abstract
E-proteins are a class of helix-loop-helix (HLH) proteins, which play multiple roles throughout lymphoid development. The DNA binding activities of the E-proteins are regulated by a distinct class of antagonistic HLH proteins, named Id1-4. Here we demonstrate that Id2 deficient mice in a C57BL/6 genetic background exhibit increased cellularity in the granulocyte/myeloid progenitor compartment and show significantly higher numbers of maturing neutrophils. Within 6 months of age, Id2 deficient mice succumbed from overwhelming granulocytosis. The disease closely mimicked the distinctive features of human chronic myeloid leukemia: leukocytosis with maturing neutrophils, splenomegaly, hepatomegaly, and myeloid infiltration into peripheral tissues, including spleen, liver, and lungs. Strikingly, forced Id2 expression in murine bone marrow cells substantially delayed the onset of myeloproliferative disease (MPD). Collectively, these studies show that suppression of E-protein activity interferes with the development of BCR-ABL-mediated MPD.
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Affiliation(s)
- Jinkyung Ko
- *Division of Biological Sciences, University of California at San Diego, La Jolla, CA 92093
| | - Nihal Patel
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111
| | - Tomokatsu Ikawa
- Laboratory for Lymphocyte Development, RIKEN Research Center for Allergy and Immunology, Yokohama 230-0045, Japan; and
| | - Hiroshi Kawamoto
- Laboratory for Lymphocyte Development, RIKEN Research Center for Allergy and Immunology, Yokohama 230-0045, Japan; and
| | - Oliver Frank
- III Medizinische Klinik, Medizinische Fakultät Mannheim der Universität Heidelberg, Wiesbadener Strasse 7-11, 68305 Mannheim, Germany
| | - Richard R. Rivera
- *Division of Biological Sciences, University of California at San Diego, La Jolla, CA 92093
| | | | - Cornelis Murre
- *Division of Biological Sciences, University of California at San Diego, La Jolla, CA 92093
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