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Qiao J, Liang C, Zhao D, Nguyen LXT, Chen F, Suo S, Hoang DH, Pellicano F, Rodriguez IR, Elhajmoussa Y, Ghoda L, Yoshimura A, Stein AS, Ali H, Koller P, Perrotti D, Copland M, Han A, Zhang BA, Marcucci G. Spred1 deficit promotes treatment resistance and transformation of chronic phase CML. Leukemia 2022; 36:492-506. [PMID: 34564700 PMCID: PMC9134843 DOI: 10.1038/s41375-021-01423-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 11/09/2022]
Abstract
Spred1 is highly expressed in normal hematopoietic stem cells (HSCs). Lack of Spred1 function has been associated with aberrant hematopoiesis and acute leukemias. In chronic myelogenous leukemia (CML), Spred1 is reduced in patients with accelerated phase (AP) or blast crisis (BC) CML, thereby suggesting that deficit of this protein may contribute to disease transformation. In fact, Spred1 knockout (KO) in SCLtTA/BCR-ABL CML mice either globally, or restricted to hematopoietic cells (i.e., HSCs) or to endothelial cells (ECs), led to transformation of chronic phase (CP) CML into AP/BC CML. Upon BCR-ABL induction, all three Spred1 KO CML models showed AP/BC features. However, compared with global Spred1 KO, the AP/BC phenotypes of HSC-Spred1 KO and EC-Spred1 KO CML models were attenuated, suggesting a concurrent contribution of Spred1 deficit in multiple compartments of the leukemic bone marrow niche to the CML transformation. Spred1 KO, regardless if occurred in HSCs or in ECs, increased miR-126 in LSKs (Lin-Sca-1+c-Kit+), a population enriched in leukemic stem cells (LSCs), resulting in expansion of LSCs, likely through hyperactivation of the MAPK/ERK pathway that augmented Bcl-2 expression and stability. This ultimately led to enhancement of Bcl-2-dependent oxidative phosphorylation that supported homeostasis, survival and activity of LSCs and drove AP/BC transformation.
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MESH Headings
- Adaptor Proteins, Signal Transducing/genetics
- Adaptor Proteins, Signal Transducing/metabolism
- Adaptor Proteins, Signal Transducing/physiology
- Animals
- Cell Transformation, Neoplastic/drug effects
- Cell Transformation, Neoplastic/metabolism
- Cell Transformation, Neoplastic/pathology
- Drug Resistance, Neoplasm
- Gene Expression Regulation, Leukemic
- Hematopoietic Stem Cells/drug effects
- Hematopoietic Stem Cells/metabolism
- Hematopoietic Stem Cells/pathology
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/metabolism
- Neoplastic Stem Cells/pathology
- Protein Kinase Inhibitors/pharmacology
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Affiliation(s)
- Junjing Qiao
- Department of Pathology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
- Phase I Clinical Research Center, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, Henan, P. R. China
| | - Chen Liang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, P. R. China
| | - Dandan Zhao
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Le Xuan Truong Nguyen
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Fang Chen
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Shanshan Suo
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P. R. China
| | - Dinh Hoa Hoang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Francesca Pellicano
- Paul O' Gorman Leukemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Ivan Rodriguez Rodriguez
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Yasmin Elhajmoussa
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Lucy Ghoda
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Anthony S Stein
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Haris Ali
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | - Paul Koller
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA
| | | | - Mhairi Copland
- Paul O' Gorman Leukemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Anjia Han
- Department of Pathology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P. R. China.
| | - Bin Amber Zhang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA.
| | - Guido Marcucci
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, City of Hope Medical Center and Beckman Research Institute, Duarte, CA, USA.
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Wang L, Li L, Chen R, Huang X, Ye X. Understanding and Monitoring Chronic Myeloid Leukemia Blast Crisis: How to Better Manage Patients. Cancer Manag Res 2021; 13:4987-5000. [PMID: 34188552 PMCID: PMC8236273 DOI: 10.2147/cmar.s314343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/13/2021] [Indexed: 12/15/2022] Open
Abstract
Chronic myeloid leukemia (CML) is triggered primarily by the t(9;22) (q34.13; q11.23) translocation. This reciprocal chromosomal translocation leads to the formation of the BCR-ABL fusion gene. Patients in the chronic phase (CP) experience a good curative effect with tyrosine kinase inhibitors. However, cases are treatment refractory, with a dismal prognosis, when the disease has progressed to the accelerated phase (AP) or blast phase (BP). Until now, few reports have provided a comprehensive description of the mechanisms involved at different molecular levels. Indeed, the underlying pathogenesis of CML evolution comprises genetic aberrations, chromosomal translocations (except for the Philadelphia chromosome), telomere biology, and epigenetic anomalies. Herein, we provide knowledge of the biology responsible for blast transformation of CML at several levels, such as genetics, telomere biology, and epigenetic anomalies. Because of the limited treatment options available and poor outcomes, only the therapeutic response is monitored regularly, which involves BCR-ABL transcript level assessment and immunologic surveillance, with the optimal treatment strategy for patients in CP adapted to evaluate disease recurrence or progression. Overall, selecting optimal treatment endpoints to predict survival and successful TFR improves the quality of life of patients. Thus, identifying risk factors and developing risk-adapted therapeutic options may contribute to a better outcome for advanced-phase patients.
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Affiliation(s)
- Lulu Wang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Program in Clinical Medicine, School of Medicine of Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Rongrong Chen
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Program in Clinical Medicine, School of Medicine of Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xianbo Huang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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3
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Pandor A, Stevenson M, Stevens J, James MMS, Hamilton J, Byrne J, Rudin C, Rawdin A, Wong R. Ponatinib for Treating Chronic Myeloid Leukaemia: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2018; 36:903-915. [PMID: 29480454 DOI: 10.1007/s40273-018-0627-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
As part of its single technology appraisal process, the National Institute for Health and Care Excellence (NICE) invited the company that manufactures ponatinib (Inclusig®; Incyte Corporation) to submit evidence for the clinical and cost effectiveness for previously treated chronic myeloid leukaemia (CML) and Philadelphia-chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL). This paper focusses on the three phases of CML: the chronic phase (CP), the accelerated phase (AP) and the blast crisis phase (BP). The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). This article presents the critical review of the company's submission by the ERG and the outcome of the NICE guidance. Clinical evidence for ponatinib was derived from a phase II, industry-sponsored, single-arm, open-label, multicentre, non-comparative study. Despite the limited evidence and potential for biases, this study demonstrated that ponatinib was likely to be an effective treatment (in terms of major cytogenetic response and major haematological response) with an acceptable safety profile for patients with CML. Given the absence of any head-to-head studies comparing ponatinib with other relevant comparators, the company undertook a matching-adjusted indirect comparison (MAIC) of ponatinib with bosutinib. The approach was only used for patients with CP-CML because comprehensive data were not available for the AP- or BP-CML groups to allow the matching technique to be used. Despite the uncertainty about the MAIC approach, ponatinib was considered likely to offer advantages over bosutinib in the third-line setting, particularly for complete cytogenetic response. The company developed two health economic models to assess the cost effectiveness of ponatinib for the treatment of patients in CP-CML or in advanced CML (AP- or BP-CML, which were modelled separately). The company did not adequately explore the uncertainty in the survivor functions. As a result, the ERG believed the uncertainty in the decision problem was underestimated. Exploratory analyses undertaken by the ERG produced the following results for ponatinib. In CP-CML, from £18,246 to £27,667 per quality-adjusted life-year (QALY) gained compared with best supportive care (BSC), from £19,680 to £37,381 per QALY gained compared with bosutinib and from £18,279 per QALY gained to dominated compared with allogeneic stem cell transplant (allo-SCT). In AP-CML, the cost per QALY gained for ponatinib ranged from £7123 to £17,625 compared with BSC, and from dominating to £61,896 per QALY gained compared with allo-SCT. In BP-CML, the cost effectiveness of ponatinib ranged from £5033 per QALY gained to dominated compared with allo-SCT, although it was likely to be at the more favourable end of this range, and dominant in all scenarios compared with BSC. The NICE appraisal committee concluded that ponatinib is a cost-effective use of NHS resources in the considered population, subject to the company providing the agreed discount in the Patient Access Scheme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Matt Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK.
| | - John Stevens
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | | | - Jean Hamilton
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Jenny Byrne
- Nottingham City Hospital, Nottingham, NG5 1PB, UK
| | | | - Andrew Rawdin
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Ruth Wong
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
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4
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Cheng L, Tang Y, Chen X, Zhao L, Liu S, Ma Y, Wang N, Zhou K, Zhou J, Zhou M. Deletion of MBD2 inhibits proliferation of chronic myeloid leukaemia blast phase cells. Cancer Biol Ther 2018; 19:676-686. [PMID: 29565710 DOI: 10.1080/15384047.2018.1450113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aberrant methylation of tumour suppressor genes is associated with the progression to a blast crisis in chronic myeloid leukaemia (CML). Methyl-CpG-binding domain protein 2 (MBD2) has been studied as a "reader" of DNA methylation in many cancers, but its role in CML is unclear. We constructed cell models of a homozygous deletion mutation of MBD2 using gene-editing technology in K562 cells and BV173 cells. Here, we demonstrated that the deletion of MBD2 inhibited cell proliferation capacity in vitro. MBD2 deletion also significantly inhibited K562 cell proliferation in a xenograft tumour model in vivo. Additionally, the JAK2/STAT3 signalling pathway, which is abnormally active in CML, was inhibited by MBD2 deletion, and MBD2 deletion could up-regulate the expression of SHP1. In conclusion, our findings suggest that MBD2 is a candidate therapeutic strategy for the CML blast phase.
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Affiliation(s)
- Ling Cheng
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Ying Tang
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Xing Chen
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Lei Zhao
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Songya Liu
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Yanna Ma
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Na Wang
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Kuangguo Zhou
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Jianfeng Zhou
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
| | - Mi Zhou
- a Department of Hematology , Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , Hubei , China
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5
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Mukherjee K, Sha X, Magimaidas A, Maifrede S, Skorski T, Bhatia R, Hoffman B, Liebermann DA. Gadd45a deficiency accelerates BCR-ABL driven chronic myelogenous leukemia. Oncotarget 2017; 8:10809-10821. [PMID: 28086219 PMCID: PMC5355225 DOI: 10.18632/oncotarget.14580] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/23/2016] [Indexed: 12/26/2022] Open
Abstract
The Gadd45a stress sensor gene is a member in the Gadd45 family of genes that includes Gadd45b & Gadd45g. To investigate the effect of GADD45A in the development of CML, syngeneic wild type lethally irradiated mice were reconstituted with either wild type or Gadd45a null myeloid progenitors transduced with a retroviral vector expressing the 210-kD BCR-ABL fusion oncoprotein. Loss of Gadd45a was observed to accelerate BCR-ABL driven CML resulting in the development of a more aggressive disease, a significantly shortened median mice survival time, and increased BCR-ABL expressing leukemic stem/progenitor cells (GFP+Lin- cKit+Sca+). GADD45A deficient progenitors expressing BCR-ABL exhibited increased proliferation and decreased apoptosis relative to WT counterparts, which was associated with enhanced PI3K-AKT-mTOR-4E-BP1 signaling, upregulation of p30C/EBPa expression, and hyper-activation of p38 and Stat5. Furthermore, Gadd45a expression in samples obtained from CML patients was upregulated in more indolent chronic phase CML samples and down regulated in aggressive accelerated phase CML and blast crisis CML. These results provide novel evidence that Gadd45a functions as a suppressor of BCR/ABL driven leukemia and may provide a unique prognostic marker of CML progression.
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Affiliation(s)
- Kaushiki Mukherjee
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA
| | - Xiaojin Sha
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA
| | - Andrew Magimaidas
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA.,Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Silvia Maifrede
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA.,Department of Microbiology and Immunology, Temple University, Philadelphia, PA, USA
| | - Tomasz Skorski
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA.,Department of Microbiology and Immunology, Temple University, Philadelphia, PA, USA
| | - Ravi Bhatia
- Division of Hematology and Oncology, University of Alabama, Tuscaloosa, AL, USA
| | - Barbara Hoffman
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA.,Department of Medical Genetics and Molecular Biochemistry, Temple University, Philadelphia, PA, USA
| | - Dan A Liebermann
- Fels Institute for Cancer Research and Molecular Biology, Philadelphia, PA, USA.,Department of Medical Genetics and Molecular Biochemistry, Temple University, Philadelphia, PA, USA
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Benedek I, Lázár E, Köpeczi JB, Benedek I, Tunyogi AB, Jakab S, Pakucs A. Unrelated Allogeneic Stem Cell Transplantation in a Patient with Chronic Myeloid Leukemia in Blast Crisis. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder, which can involve the hematopoietic stem cell or early progenitor cells, without the loss of their capacity to differentiate. Typically, CML has three clinical phases: a chronic phase, an accelerated phase, and an aggressive transformation in blast crisis, analogous to acute leukemia. The following article presents the case of a 49-year-old patient diagnosed with Philadelphia-negative CML in blastic transformation, where after multiple conventional acute leukemia induction chemotherapy regimens an unrelated allogeneic hematopoietic stem cell transplant was performed.
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Affiliation(s)
- István Benedek
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Erzsébet Lázár
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Judit Beáta Köpeczi
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
| | - István Benedek
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Aliz Beáta Tunyogi
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Szende Jakab
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Annamária Pakucs
- Clinic of Hematology and Bone Marrow Transplantation Unit , Tîrgu Mureș , Romania
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Pan CY, Xu N, He BL, Cao R, Liao LB, Yin CX, Lan YQ, Lu ZY, Huang JX, Sun J, Feng R, Liu QF, Liu XL. [Clinical significance of cytogenetic monitoring in chronic myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:112-117. [PMID: 28279034 PMCID: PMC7354167 DOI: 10.3760/cma.j.issn.0253-2727.2017.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: To analyze the association of cytogenetic abnormalities with the prognosis of chronic myeloid leukemia (CML) patients in tyrosine kinase inhibitors (TKI) era. Methods: Karyotype analysis of chromosome G-banding was carried out in 387 newly diagnosed CML patients by short-term culture of bone marrow cells. The correlation of cytogenetic abnormalities and CML progression was explored in combination with ABL tyrosine point mutations. Result: Of 387 patients with positive BCR-ABL fusion gene assayed by fluorescence in situ hybridization (FISH) technique, 94.1% (364/387) patients were Ph positive and 5.9% (23/387) Ph negative; 320 patients (87.9%) had a translocation t (9;22) (q34;q11) and 5 (1.4%) a variant translocation t (v;22) . Additional cytogenetic aberrations (ACA) at diagnosis were found in 10.7% (39/387) Ph(+) patients, major route ACA in 22 (56.4%) cases and minor route ACA in 15 (38.5%) cases and 2 patients (5.1%) lacked the Y chromosome (-Y) ; 23.4% (71/303) patients occurred ACA during TKI treatment and the most frequent abnormalities were abnormal chromosome numbersd, which were likely associated with high proportion of disease progression (χ(2)=168.21, P<0.001) and ABL tyrosine point mutations (χ(2)=29.04, P<0.001) . Newly diagnosed CML-CP patients with t (9;22) (q34;q11) had a longer event-free survival (EFS) and disease-free survival (DFS) rates than that of patients with ACA (P=0.037; P=0.003) , while the overall survival (OS) had no significant differences (P=0.209) . As for CML-CP patients that occurred ACA during TKI therapy would have a marked low OS, EFS and DFS (all P<0.001) compared with no ACA occurred patients. Survival of advanced patients that occurred ACA were dramatically reduced. Conclusion: ACA often emerged during the disease progress in CML patients, regular and timely detection of chromosomes karyotype and ABL tyrosine point mutations during TKI treatment was important for therapeutic evaluation, progress and prognosis of CML.
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Affiliation(s)
- C Y Pan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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8
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Cytogenetic landscape and impact in blast phase of chronic myeloid leukemia in the era of tyrosine kinase inhibitor therapy. Leukemia 2016; 31:585-592. [PMID: 27560111 DOI: 10.1038/leu.2016.231] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/01/2016] [Accepted: 08/04/2016] [Indexed: 12/21/2022]
Abstract
The landscape of additional chromosomal alterations (ACAs) and their impact in chronic myeloid leukemia, blast phase (CML-BP) treated with tyrosine kinase inhibitors (TKIs) have not been well studied. Here, we investigated a cohort of 354 CML-BP patients treated with TKIs. We identified +8, an extra Philadelphia chromosome (Ph), 3q26.2 rearrangement, -7 and isochromosome 17q (i(17q)) as the major-route changes with a frequency of over 10%. In addition, +21 and +19 had a frequency of over 5%. These ACAs demonstrated lineage specificity: +8, 3q26.2 rearrangement, i(17q) and +19 were significantly more common in myeloid BP, and -7 more common in lymphoid BP; +Ph and +21 were equally distributed between two groups. Pearson correlation analysis revealed clustering of common ACAs into two groups: 3q26.2 rearrangement, -7 and i(17q) formed one group, and other ACAs formed another group. The grouping correlated with risk stratification of ACAs in CML, chronic phase. Despite the overall negative prognostic impact of ACAs, stratification of ACAs into major vs minor-route changes provided no prognostic relevance in CML-BP. The emergence of 3q26.2 rearrangement as a major-route change in the TKI era correlated with a high frequency of ABL1 mutations, supporting a role for TKI resistance in the changing cytogenetic landscape in CML-BP.
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Pérez-Jacobo F, Tuna-Aguilar E, Demichelis-Gómez R, Crespo-Solís E, Valencia-Rocha U, Aguayo Á, López-Karpovitch X. Prognostic Factors, Response to Treatment, and Survival in Patients With Chronic Myeloid Leukemia in Blast Phase: A Single-Institution Survey. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:778-84. [PMID: 26500135 DOI: 10.1016/j.clml.2015.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/21/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Data from 51 patients (23 women) with chronic myeloid leukemia (CML) in blast phase (BP) were analyzed in order to identify prognostic factors for complete hematologic response (CHR) and survival. PATIENTS AND METHODS Forty-four patients experienced disease progression from chronic or accelerated phase, and 7 cases presented as CML-BP. Thirteen patients (25.5%) had extramedullary involvement at diagnosis, and 71% were myeloid BP. Clonal evolution was identified in 53% of the cases, and the abnormalities most frequently observed were isochromosome (17q), double Philadelphia chromosome, and trisomy 8. Forty-five patients received treatment: 60% chemotherapy (CT) alone and 40% CT plus tyrosine kinase inhibitors (TKI) or TKI alone; 42% of them experienced CHR. RESULTS Median overall survival (OS) in patients whose disease responded to treatment was 7 months (95% confidence interval, 1.7-6.2 months), with a median disease-free survival of 5 months (95% confidence interval, 2.8-5.8 months). One out of 3 patients who underwent hematopoietic stem-cell transplantation remains alive. Multivariate analysis revealed that lymphoid BP and TKI therapy had a statistically significant positive impact as prognostic factors for CHR. In the multivariate analysis, age > 60 years, hemoglobin < 10 g/dL, and complex karyotype were statistically significant negative prognostic factors for OS. There was no statistical significant difference in OS between patients who received only CT (1988-2002) with those treated with CT plus TKI (2003-2013). CONCLUSION This is the first study in Mexico to report prognostic factors associated with CHR and OS in patients with CML-BP.
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Affiliation(s)
- Fernando Pérez-Jacobo
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Elena Tuna-Aguilar
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Roberta Demichelis-Gómez
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Erick Crespo-Solís
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Ubaldo Valencia-Rocha
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Álvaro Aguayo
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México
| | - Xavier López-Karpovitch
- Chronic Leukemia Clinic, Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, México.
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10
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Abstract
PURPOSE OF REVIEW Pulmonary manifestations have been well described in leukemia, but pleural disease is less common. This review highlights pleural effusions in acute and chronic leukemia and myelodysplastic syndrome (MDS) based on the evidence to date. Diagnostic workup and recommendations for the management of these effusions are also outlined. RECENT FINDINGS Pleural effusions in patients with leukemia are most often due to infection and to a lesser extent leukemic infiltration of the pleura. The prognostic implications of these effusions are unclear, but survival is most likely determined by the underlying malignancy and its response to treatment. New therapies have changed survival in these patients, and some of these treatments, such as tyrosine kinase inhibitors, have emerged as important causes for these effusions. Pleural interventions may be accomplished with few complications. SUMMARY Pleural effusions may occur with acute and chronic leukemia and MDS. Infection remains the most common cause. Malignant pleural effusions tend to occur in advanced disease in chronic leukemia, but they can be seen at any time with acute leukemia and MDS. With standard precautions, pleural procedures may be performed safely in this population. In cases of unclear cause, pleural and bone marrow biopsy should be considered.
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11
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Sahu KK, Malhotra P, Uthamalingam P, Prakash G, Bal A, Varma N, Varma SC. Chronic Myeloid Leukemia with Extramedullary Blast Crisis: Two Unusual Sites with Review of Literature. Indian J Hematol Blood Transfus 2014; 32:89-95. [PMID: 27408365 DOI: 10.1007/s12288-014-0471-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/20/2014] [Indexed: 11/26/2022] Open
Abstract
Extramedullary blast crisis (EBC) in chronic myeloid leukemia (CML) is a rare phenomenon and represents infiltration of leukemic blasts in areas other than bone marrow. Lymph node is the most common site of involvement by EBC. We herein present a case of CML who suffered from two discrete episodes of EBC at atypical locations (scalp and paravertebral) within an interval duration of nine months. A-38-year-old female was diagnosed as a case of CML with extramedullary blast crisis in scalp at presentation. She received treatment with imatinib 600 mg once daily through Novartis Oncology Access Program (NOA). She achieved hematological remission. However nine months later she was readmitted with spinal shock due to cord compression secondary to paraspinal chloroma. She was started on tablet Nilotinib in view of failure to 1st line therapy. Her compressive myelopathy was treated with pulses of high dose dexamethasone. However soon she died due to pneumonia.
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Affiliation(s)
- Kamal Kant Sahu
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Preithy Uthamalingam
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Subhash Chandar Varma
- Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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12
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Tsunemine H, Arima H, Itoh K, Sakane-Ishikawa E, Akasaka H, Kodaka T, Takahashi T. Monocytic crisis of chronic myeloid leukemia in the era of tyrosine kinase inhibitor. J Clin Exp Hematop 2013; 53:227-33. [PMID: 24369225 DOI: 10.3960/jslrt.53.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
A 47-year-old man was diagnosed with Philadelphia chromosome-positive chronic myeloid leukemia (CML) in October 2005. He could not receive treatment with imatinib mesylate due to his economic circumstances. He was consequently treated with hydroxyurea with partial hematological remission until June 2008. Although imatinib mesylate was started thereafter, the adherence to this treatment was poor because of his occupational circumstances. In September 2009, imatinib mesylate was switched to nilotinib, with a subsequent phase of acceleration of the disease, presumably due to his poor adherence to the treatment. Dasatinib was started in September 2010, with transient hematological response and final blastic crisis of the disease in January 2011, regardless of improved adherence. Blast cells showed immature monocytic morphology and were positive for α-naphtylbutyrate esterase staining. They also expressed surface CD14 and CD64 antigens. A diagnosis of rare monocytic crisis of CML was made. He was treated with low-dose nilotinib following cytoreduction with MEC (mitoxantrone, etoposide, and cytarabine) chemotherapy. Severe leucopenia without circulating leukemic cells continued for about 2 months with sustained hepatosplenomegaly, and he died of pneumonia in March 2012. Necropsy showed severe bone marrow hypoplasia with focal infiltration of mature leukemic cells and similar infiltration in the liver.
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13
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Strati P, Kantarjian H, Thomas D, O'Brien S, Konoplev S, Jorgensen JL, Luthra R, Abruzzo L, Jabbour E, Quintas-Cardama A, Borthakur G, Faderl S, Ravandi F, Cortes J. HCVAD plus imatinib or dasatinib in lymphoid blastic phase chronic myeloid leukemia. Cancer 2013; 120:373-80. [PMID: 24151050 DOI: 10.1002/cncr.28433] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 08/27/2013] [Accepted: 09/12/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic myeloid leukemia (CML) may progress to blast phase (BP) at the rate of 1% to 1.5% per year. With the use of single-agent tyrosine kinase inhibitors, median overall survival ranges between 7 and 11 months. METHODS The outcome was analyzed for 42 patients with lymphoid BP-CML who were treated with hyperfractionated cyclophosphamide, vincristine, Adriamycin, dexamethasone (HCVAD) plus imatinib or dasatinib. RESULTS Complete hematological response was achieved in 90% of patients, complete cytogenetic remission in 58%, and complete molecular remission in 25%. Flow cytometry minimal residual disease negativity was achieved by 42% of evaluable patients after induction. Eighteen patients received allogeneic stem cell transplant (SCT) while in first complete hematological response. Median remission duration was 14 months and was longer among SCT recipients (P = .01) on multivariate analysis. Median overall survival was 17 months (range, 7-27 months) and was longer among SCT recipients (P < .001) and patients treated with dasatinib (P = .07) on multivariate analysis. Although a high rate of hematologic toxicity (100%) and infectious complications (59%) were observed, the related rate of treatment discontinuation was low (7% and 9%, respectively). CONCLUSIONS HCVAD combined with tyrosine kinase inhibitors is an effective regimen for the management of BP-CML, particularly when followed by allogeneic SCT.
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Affiliation(s)
- Paolo Strati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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14
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Goff DJ, Court Recart A, Sadarangani A, Chun HJ, Barrett CL, Krajewska M, Leu H, Low-Marchelli J, Ma W, Shih AY, Wei J, Zhai D, Geron I, Pu M, Bao L, Chuang R, Balaian L, Gotlib J, Minden M, Martinelli G, Rusert J, Dao KH, Shazand K, Wentworth P, Smith KM, Jamieson CAM, Morris SR, Messer K, Goldstein LSB, Hudson TJ, Marra M, Frazer KA, Pellecchia M, Reed JC, Jamieson CHM. A Pan-BCL2 inhibitor renders bone-marrow-resident human leukemia stem cells sensitive to tyrosine kinase inhibition. Cell Stem Cell 2013; 12:316-28. [PMID: 23333150 DOI: 10.1016/j.stem.2012.12.011] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 11/09/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
Abstract
Leukemia stem cells (LSCs) play a pivotal role in the resistance of chronic myeloid leukemia (CML) to tyrosine kinase inhibitors (TKIs) and its progression to blast crisis (BC), in part, through the alternative splicing of self-renewal and survival genes. To elucidate splice-isoform regulators of human BC LSC maintenance, we performed whole-transcriptome RNA sequencing, splice-isoform-specific quantitative RT-PCR (qRT-PCR), nanoproteomics, stromal coculture, and BC LSC xenotransplantation analyses. Cumulatively, these studies show that the alternative splicing of multiple prosurvival BCL2 family genes promotes malignant transformation of myeloid progenitors into BC LSCS that are quiescent in the marrow niche and that contribute to therapeutic resistance. Notably, sabutoclax, a pan-BCL2 inhibitor, renders marrow-niche-resident BC LSCs sensitive to TKIs at doses that spare normal progenitors. These findings underscore the importance of alternative BCL2 family splice-isoform expression in BC LSC maintenance and suggest that the combinatorial inhibition of prosurvival BCL2 family proteins and BCR-ABL may eliminate dormant LSCs and obviate resistance.
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Affiliation(s)
- Daniel J Goff
- Stem Cell Program, Department of Medicine, Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093, USA
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15
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Li Y, Shao J, Shen K, Xu Y, Liu J, Qian X. E2F1-dependent pathways are involved in amonafide analogue 7-d-induced DNA damage, G2/M arrest, and apoptosis in p53-deficient K562 cells. J Cell Biochem 2013; 113:3165-77. [PMID: 22593008 DOI: 10.1002/jcb.24194] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The E2F1 gene well known is its pivotal role in regulating the entry from G1 to S phase, while the salvage antitumoral pathway which implicates it, especially in the absence of p53, is not fully characterized. We therefore attempted to identify the up- and down-stream events involved in the activation of the E2F1-dependent pro-apoptotic pathway. For this purpose, a amonafide analogue, 7-d (2-(3-(2-(Dimethylamino)ethylamino)propyl)-6-(dodecylamino)-1H-benzo[de]isoquinoline-1,3(2H)-dione) was screened, which exhibited high antitumor activity against p53-deficient human Chronic Myelogenous Leukemia (CML) K562 cells. Analysis of flow cytometry and western blots of K562 cells treated with 7-d revealed an appreciable G2/M cycle arrest and apoptosis in a dose and time-dependent manner via p53-independent pathway. A striking increase in "Comet tail" formation and γ-H2AX expression showed that DNA double strand breaks (DSB) were caused by 7-d treatment. ATM/ATR signaling was reported to connect E2F1 induction with apoptosis in response to DNA damage. Indeed, 7-d-induced G2/M arrest and apoptosis were antagonized by ATM/ATR signaling inhibitor, Caffeine, which suggested that ATM/ATR signaling was activated by 7-d treatment. Furthermore, the increased expression of E2F1, p73, and Apaf-1 and p73 dissociation from HDM2 was induced by 7-d treatment, however, knockout of E2F1 expression reversed p73, Apaf-1, and p21(Cip1/WAF1) expression, reactivated cell cycle progression, and inhibited 7-d-induced apoptosis. Altogether our results for the first time indicate that 7-d mediates its growth inhibitory effects on CML p53-deficient cells via the activation of an E2F1-dependent mitochondrial and cell cycle checkpoint signaling pathway which subsequently targets p73, Apaf-1, and p21(Cip1/WAF1).
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Affiliation(s)
- Yiquan Li
- State Key Laboratory of Bioreactor Engineering & Shanghai Key Laboratory of Chemical Biology, School of Pharmacy, East China University of Science and Technology, #268, 130 Meilong Road, Shanghai 200237, PR China
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16
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Burns TA, Subathra M, Signorelli P, Choi Y, Yang X, Wang Y, Villani M, Bhalla K, Zhou D, Luberto C. Sphingomyelin synthase 1 activity is regulated by the BCR-ABL oncogene. J Lipid Res 2012; 54:794-805. [PMID: 23160178 DOI: 10.1194/jlr.m033985] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Sphingomyelin synthase (SMS) produces sphingomyelin while consuming ceramide (a negative regulator of cell proliferation) and forming diacylglycerol (DAG) (a mitogenic factor). Therefore, enhanced SMS activity could favor cell proliferation. To examine if dysregulated SMS contributes to leukemogenesis, we measured SMS activity in several leukemic cell lines and found that it is highly elevated in K562 chronic myelogenous leukemia (CML) cells. The increased SMS in K562 cells was caused by the presence of Bcr-abl, a hallmark of CML; stable expression of Bcr-abl elevated SMS activity in HL-60 cells while inhibition of the tyrosine kinase activity of Bcr-abl with Imatinib mesylate decreased SMS activity in K562 cells. The increased SMS activity was the result of up-regulation of the Sms1 isoform. Inhibition of SMS activity with D609 (a pharmacological SMS inhibitor) or down-regulation of SMS1 expression by siRNA selectively inhibited the proliferation of Bcr-abl-positive cells. The inhibition was associated with an increased production of ceramide and a decreased production of DAG, conditions that antagonize cell proliferation. A similar change in lipid profile was also observed upon pharmacological inhibition of Bcr-abl (K526 cells) and siRNA-mediated down-regulation of BCR-ABL (HL-60/Bcr-abl cells). These findings indicate that Sms1 is a downstream target of Bcr-abl, involved in sustaining cell proliferation of Bcr-abl-positive cells.
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Affiliation(s)
- Tara Ann Burns
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC
| | - Marimuthu Subathra
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC
| | - Paola Signorelli
- Laboratory of Biochemistry and Molecular Biology, San Paolo University Hospital, Medical School, University of Milan, Italy
| | - Young Choi
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC
| | - Xiaofeng Yang
- Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC
| | - Yong Wang
- Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC
| | - Maristella Villani
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC; Pathology and Laboratory Medicine, Polispecialistica Bios, Crotone, Italy
| | - Kapil Bhalla
- Pathology and Laboratory Medicine, The University of Kansas Cancer Center, Kansas City, KS
| | - Daohong Zhou
- Division of Radiation Health, Department of Pharmaceutical Sciences, and Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Chiara Luberto
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC
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Bernardo PS, Reis FRDS, Maia RC. Imatinib increases apoptosis index through modulation of survivin subcellular localization in the blast phase of CML cells. Leuk Res 2012; 36:1510-6. [PMID: 22975581 DOI: 10.1016/j.leukres.2012.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 07/03/2012] [Accepted: 08/09/2012] [Indexed: 01/20/2023]
Abstract
Using MTT, Annexin V/flow cytometry, immunocytochemistry, subcellular fractionation, and Western blotting assays we analyzed the effect of imatinib in two blast phase of chronic myeloid leukemia (CML) cell lines: K562 P-glycoprotein (Pgp)-negative, and Lucena, Pgp-positive. In K562 cell line, the high apoptosis index induced by imatinib was associated with the survivin predominantly in the nucleus. In the Lucena cell line, the low apoptosis index induced by imatinib was associated with a cytoplasmatic survivin localization. Pgp and survivin might be subject to the same molecular regulation, and therefore represent a therapeutic target in the blast phase of CML.
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Affiliation(s)
- Paula Sabbo Bernardo
- Laboratório de Hemato-Oncologia Celular e Molecular, Programa de Pesquisa em Hemato-Oncologia Molecular, Instituto Nacional de Câncer (INCA), Rio de Janeiro (RJ), Brazil
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18
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Antitumor effect of betulinic acid on human acute leukemia K562 cells in vitro. ACTA ACUST UNITED AC 2010; 30:453-7. [DOI: 10.1007/s11596-010-0448-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Indexed: 12/14/2022]
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19
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Cooper S, Giles FJ, Savona MR. Overcoming resistance in chronic myelogenous leukemia. Leuk Lymphoma 2009; 50:1785-93. [DOI: 10.3109/10428190903267559] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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20
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Giles FJ, DeAngelo DJ, Baccarani M, Deininger M, Guilhot F, Hughes T, Mauro M, Radich J, Ottmann O, Cortes J. Optimizing Outcomes for Patients With Advanced Disease in Chronic Myelogenous Leukemia. Semin Oncol 2008; 35:S1-17; quiz S18-20. [DOI: 10.1053/j.seminoncol.2007.12.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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