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NK Cells in Myeloproliferative Neoplasms (MPN). Cancers (Basel) 2021; 13:cancers13174400. [PMID: 34503210 PMCID: PMC8431564 DOI: 10.3390/cancers13174400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary NK cells are important innate immune effectors that contribute substantially to tumor control, however the role of NK cells in haematological cancers is not as well understood. The aim of this review is to highlight the importance of the role of NK cells in the management of Ph+ Myeloproliferative Neoplasms, and emphasize the need and possible benefits of a more in-depth investigation into their role in classical MPNs and show potential strategies to harness the anti-tumoral capacities of NK cells. Abstract Myeloproliferative neoplasms (MPNs) comprise a heterogenous group of hematologic neoplasms which are divided into Philadelphia positive (Ph+), and Philadelphia negative (Ph−) or classical MPNs. A variety of immunological factors including inflammatory, as well as immunomodulatory processes, closely interact with the disease phenotypes in MPNs. NK cells are important innate immune effectors and substantially contribute to tumor control. Changes to the absolute and proportionate numbers of NK cell, as well as phenotypical and functional alterations are seen in MPNs. In addition to the disease itself, a variety of therapeutic options in MPNs may modify NK cell characteristics. Reports of suppressive effects of MPN treatment strategies on NK cell activity have led to intensive investigations into the respective compounds, to elucidate the possible negative effects of MPN therapy on control of the leukemic clones. We hereby review the available literature on NK cells in Ph+ and Ph− MPNs and summarize today’s knowledge on disease-related alterations in this cell compartment with particular focus on known therapy-associated changes. Furthermore, we critically evaluate conflicting data with possible implications for future projects. We also aim to highlight the relevance of full NK cell functionality for disease control in MPNs and the importance of considering specific changes related to therapy in order to avoid suppressive effects on immune surveillance.
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Kumagai T, Nakaseko C, Nishiwaki K, Yoshida C, Ohashi K, Takezako N, Takano H, Kouzai Y, Murase T, Matsue K, Morita S, Sakamoto J, Wakita H, Sakamaki H, Inokuchi K. Silent NK/T cell reactions to dasatinib during sustained deep molecular response before cessation are associated with longer treatment-free remission. Cancer Sci 2020; 111:2923-2934. [PMID: 32614159 PMCID: PMC7419041 DOI: 10.1111/cas.14518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 12/18/2022] Open
Abstract
This study presents the final report of the multicenter, prospective tyrosine kinase inhibitor discontinuation study, D-STOP, after a 3-year follow-up of 54 patients with chronic CML who discontinued dasatinib after a sustained deep molecular response (DMR) for ≥2 years with dasatinib treatment. Estimated treatment-free remission (TFR) rates at 12 and 36 months were 63.0% [95% confidence interval (CI): 48.7-74.3] and 59.3% (95% CI: 45.0-71.0), respectively. CD3- CD56+ NK, CD16+ CD56+ NK, and CD57+ CD56+ NK large granular lymphocyte (NK-LGL), CD8+ CD4- cytotoxic T cell, and CD57+ CD3+ T-LGL cell numbers were relatively elevated throughout the 24-month consolidation only in failed patients who molecularly relapsed within 12 months. In successful patients, these subsets elevated transiently after 12 months, but returned to basal levels after 24-month consolidation. Therefore, smaller changes in NK/T, particularly the NK subset throughout consolidation, reflected higher TFR rates. TFR rates of those patients exhibiting elevation in CD3- CD56+ NK >376 cells/μL, CD16+ CD56+ NK > 241 cells/μL, or CD57+ CD56+ NK-LGL >242 cells/μL during consolidation compared with others were 26.7% (8.3%-49.6%) vs 78.3% (55.4%-90.3%), HR 0.032 (0.0027-0.38; P = .0064), 31.2% (11.4%-53.6%) vs 85.0% (60.4%-94.9%), HR 0.039 (0.0031-0.48; P = .011), or 36.8% (16.5%-57.5%) vs 77.3% (53.7%-89.8%), HR 0.21 (0.065-0.69; P = .010), respectively. Therefore, silent responses of T/NK subsets to dasatinib throughout consolidation were significant for longer TFR. Elevated NK/T, particularly NK lymphocytes responsive to dasatinib, may be immunologically insufficient to maintain TFR. Their decline, subsequently replaced by altered lymphocyte population with less response to dasatinib during sustained DMR, might be immunologically significant. (D-STOP, NCT01627132).
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Affiliation(s)
- Takashi Kumagai
- Department of Hematology, Ome Municipal General Hospital, Tokyo, Japan
| | - Chiaki Nakaseko
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Kaichi Nishiwaki
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Chikashi Yoshida
- Department of Hematology, National Hospital Organization, Mito Medical Center, Higashiibarakigun, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center, Tachikawa, Japan
| | - Hina Takano
- Department of Hematology, Musashino Red Cross Hospital, Musashino, Japan
| | - Yasuji Kouzai
- Department of Hematology, Tokyo Metropolitan Tama Synthesis Medical Center, Tokyo, Japan
| | - Tadashi Murase
- Department of Laboratory Medicine, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Society, Narita Red Cross Hosp, Narita, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Department of Hematology, Nippon Medical School, Tokyo, Japan
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Dasatinib-induced anti-leukemia cellular immunity through a novel subset of CD57 positive helper/cytotoxic CD4 T cells in chronic myelogenous leukemia patients. Int J Hematol 2018; 108:588-597. [PMID: 30151740 DOI: 10.1007/s12185-018-2517-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
Dasatinib induces lymphocytosis of large granular lymphocytes (LGLs) in a proportion of patients with chronic myelogenous leukemia (CML), and is associated with better clinical outcomes. LGLs consist of cytotoxic T lymphocytes and natural killer cells; however, the context and phenotypic/functional features of each type of LGL are unknown. To better define features of these LGLs, we investigated lymphocytosis in CML patients treated with dasatinib. D57-positive and CD4-positive type I T-helper (Th) cells (CD57+ Th cells) rarely occur in CML patients without lymphocytosis and in healthy individuals; however, a substantial increase in the proportion of CD57+ Th cells was observed in CML patients treated with dasatinib. In addition, these cells showed appreciable levels of cytocidal activity via cytotoxic degranulation. Analysis of T-cell receptor α and β sequences showed a skewed T-cell repertoire in the CD57+ Th cells. Furthermore, patients with LGLs and CD57+ Th lymphocytosis achieved stronger molecular responses than did those without lymphocytosis. While further studies are warranted, our observations suggest that dasatinib induces the expansion of CD57+ Th-LGLs, which may play a crucial role in the dasatinib-induced response against Philadelphia chromosome-positive leukemia.
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Iriyama N, Takahashi H, Miura K, Uchino Y, Nakagawa M, Hatta Y, Takei M. Enhanced perforin expression associated with dasatinib therapy in natural killer cells. Leuk Res 2018; 68:1-8. [DOI: 10.1016/j.leukres.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 02/02/2018] [Accepted: 02/23/2018] [Indexed: 12/21/2022]
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Regulatory T cell inhibition by dasatinib is associated with natural killer cell differentiation and a favorable molecular response—The final results of the D-first study. Leuk Res 2018; 66:66-72. [DOI: 10.1016/j.leukres.2018.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 11/20/2022]
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Inokuchi K, Nakayama K, Tauchi T, Takaku T, Yokose N, Yamaguchi H, Kumagai T, Komatsu N, Ohyashiki K. Therapeutic effects of tyrosine kinase inhibitors and subtypes of BCR-ABL1 transcripts in Japanese chronic myeloid leukemia patients with three-way chromosomal translocations. Leuk Res 2018; 65:74-79. [PMID: 29310021 DOI: 10.1016/j.leukres.2018.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/30/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
Abstract
We analyzed the clinical responses to thyrosine kinase inhibitors (TKIs) and the molecular and cytogenetic characteristics of 18 chronic myeloid leukemia (CML) patients with 3-way chromosomal translocations. The patients were 14 men and 4 women, aged 23-75 years (median 57 years). The Sokal risk was low in 12 patients, intermediate in 4 patients, and high in 2 patients. Newly identified translocation breakpoints were seen in 7 of the 18 patients. Three patients had the same breakpoints of t(9;22;11)(q34;q11.2;q23). The best responses to TKIs were partial cytogenic response (PCyR) in 2 patients, complete cytogenic response (CCyR) in 3 patients, molecular response (MR) 3.0 in 7 patients, MR 4.0 in 3 patients, and MR 4.5 or higher in 3 patients. A total of 66.7% of patients did not achieve MR 4.0 or higher. In 3 patients in whom TKIs resulted in MR 4.5 or higher for more than 2 years, TKI treatment was discontinued. However, all of them exhibited a loss of MR3.0, at 2, 6, and 20 months after the discontinuation of treatment, respectively, and TKI treatment needed to be restarted. According to Kaplan-Meier survival curve analysis, the overall survival (OS) was 100 months in 56% of the patients. The 60-months cumulative incidences of CCyR, MR3.0, MR4.0 and MR4.5 were 88.9%, 72.2%, 33.3%, and 16.7%, respectively. In the 11 analyzable patients, the BCR-ABL1 mRNA subtype was e14a2 type in 4 patients and e13a2 type in 7 patients.
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Affiliation(s)
- Koiti Inokuchi
- Department of Hematology, Nippon Medical School, Tokyo, Japan.
| | | | - Tetsuzo Tauchi
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Tomoiku Takaku
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Yokose
- Department of Hematology, Chiba Hokusoh Hospital, Nippon Medical School, Japan
| | | | - Takashi Kumagai
- Department of Hematology, Ome Municipal General Hospital, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
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Iriyama N, Ohashi K, Hashino S, Kimura S, Nakaseko C, Takano H, Hino M, Uchiyama M, Morita S, Sakamoto J, Sakamaki H, Inokuchi K. The Efficacy of Reduced-dose Dasatinib as a Subsequent Therapy in Patients with Chronic Myeloid Leukemia in the Chronic Phase: The LD-CML Study of the Kanto CML Study Group. Intern Med 2018; 57:17-23. [PMID: 29033428 PMCID: PMC5799051 DOI: 10.2169/internalmedicine.9035-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective The aim of this study was to prospectively investigate the efficacy and safety profiles of low-dose dasatinib therapy (50 mg once daily). Methods Patients with chronic myeloid leukemia in the chronic phase (CML-CP) who were being treated with low-dose imatinib (≤200 mg/day), but were resistant to this agent were enrolled in the current study (referred to as the LD-CML study). Results There subjects included 9 patients (4 men and 5 women); all were treated with dasatinib at a dose of 50 mg once daily. Among 8 patients who had not experienced major molecular response (MMR; BCR-ABL1 transcript ≤0.1% according to International Scale [IS]) at study enrollment, 5 attained MMR by 12 months. In particular, 3 of 9 patients demonstrated a deep molecular response (DMR; IS ≤0.0069%) by 18 months. Five patients developed lymphocytosis accompanied by cytotoxic lymphocyte predominance. There was no mortality or disease progression, and all continue to receive dasatinib therapy at 18 months with only 2 patients requiring dose reduction. Toxicities were mild-to-moderate, and pleural effusion was observed in 1 patient (grade 1). Conclusion Low-dose dasatinib can attain MMR and DMR without severe toxicity in patients with CML-CP who are unable to achieve MMR with low-dose imatinib. Switching to low-dose dasatinib should therefore be considered for patients in this setting, especially if they are otherwise considering a cessation of treatment.
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Affiliation(s)
- Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | | | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
| | | | - Hina Takano
- Department of Hematology, Musashino Red Cross Hospital, Japan
| | - Masayuki Hino
- Department of Hematology, Osaka City University Hospital, Japan
| | | | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Japan
| | | | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
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Kumagai T, Nakaseko C, Nishiwaki K, Yoshida C, Ohashi K, Takezako N, Takano H, Kouzai Y, Murase T, Matsue K, Morita S, Sakamoto J, Wakita H, Sakamaki H, Inokuchi K. Dasatinib cessation after deep molecular response exceeding 2 years and natural killer cell transition during dasatinib consolidation. Cancer Sci 2017; 109:182-192. [PMID: 29058817 PMCID: PMC5765311 DOI: 10.1111/cas.13430] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/12/2017] [Accepted: 10/17/2017] [Indexed: 01/12/2023] Open
Abstract
Tyrosine kinase inhibitors (TKI) improve the prognosis of patients with chronic myelogenous leukemia (CML) by inducing substantial deep molecular responses (DMR); some patients have successfully discontinued TKI therapy after maintaining DMR for ≥1 year. In this cessation study, we investigated the optimal conditions for dasatinib discontinuation in patients who maintained DMR for ≥2 years. This study included 54 patients with CML who were enrolled in a D‐STOP multicenter prospective trial, had achieved DMR, and had discontinued dasatinib after 2‐year consolidation. Peripheral lymphocyte profiles were analyzed by flow cytometry. The estimated 12‐month treatment‐free survival (TFS) was 62.9% (95% confidence interval: 48.5%‐74.2%). During dasatinib consolidation, the percentage of total lymphocytes and numbers of CD3− CD56+ natural killer (NK) cells, CD16+ CD56+ NK cells and CD56+ CD57+ NK‐large granular lymphocytes (LGL) were significantly higher in patients with molecular relapse after discontinuation but remained unchanged in patients without molecular relapse for >7 months. At the end of consolidation, patients whose total lymphocytes comprised <41% CD3− CD56+ NK cells, <35% CD16+ CD56+ NK cells, or <27% CD56+ CD57+ NK‐LGL cells had higher TFS relative to other patients (77% vs 18%; P < .0008; 76% vs 10%; P < .0001; 84% vs 46%; P = .0059, respectively). The increase in the number of these NK cells occurred only during dasatinib consolidation. In patients with DMR, dasatinib discontinuation after 2‐year consolidation can lead to high TFS. This outcome depends significantly on a smaller increase in NK cells during dasatinib consolidation.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/pharmacology
- Consolidation Chemotherapy
- Dasatinib/administration & dosage
- Dasatinib/pharmacology
- Disease-Free Survival
- Female
- Flow Cytometry
- Fusion Proteins, bcr-abl/genetics
- Humans
- Killer Cells, Natural/cytology
- Killer Cells, Natural/drug effects
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Prospective Studies
- Withholding Treatment
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Affiliation(s)
- Takashi Kumagai
- Department of HematologyOme Municipal General HospitalTokyoJapan
| | | | - Kaichi Nishiwaki
- Division of Clinical Oncology and HematologyDepartment of Internal MedicineJikei University School of MedicineKashiwa HospitalChibaJapan
| | - Chikashi Yoshida
- Department of HematologyNational Hospital OrganizationMito Medical CenterHigashiibarakigunJapan
| | - Kazuteru Ohashi
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases CenterKomagome HospitalTokyoJapan
| | - Naoki Takezako
- Department of HematologyNational Hospital Organization Disaster Medical CenterTachikawaJapan
| | - Hina Takano
- Department of HematologyMusashino Red Cross HospitalMusashinoJapan
| | - Yasuji Kouzai
- Department of HematologyTokyo Metropolitan Tama Synthesis Medical CenterTokyoJapan
| | - Tadashi Murase
- Department of Laboratory MedicineDokkyo Medical University Koshigaya HospitalSaitamaJapan
| | - Kosei Matsue
- Division of Hematology/OncologyDepartment of Internal MedicineKameda Medical CenterKamogawaJapan
| | - Satoshi Morita
- Department of Biomedical Statistics and BioinformaticsKyoto University Graduate School of MedicineKyotoJapan
| | | | - Hisashi Wakita
- Division of Hematology and OncologyJapanese Red Cross SocietyNarita Red Cross HospitalNaritaJapan
| | - Hisashi Sakamaki
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases CenterKomagome HospitalTokyoJapan
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NK cell dynamics and association with molecular response in early chronic phase chronic myelogenous leukemia (CML-CP) patients treated with nilotinib. Leukemia 2017; 31:2264-2267. [DOI: 10.1038/leu.2017.235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Shiseki M, Yoshida C, Takezako N, Ohwada A, Kumagai T, Nishiwaki K, Horikoshi A, Fukuda T, Takano H, Kouzai Y, Tanaka J, Morita S, Sakamoto J, Sakamaki H, Inokuchi K. Dasatinib rapidly induces deep molecular response in chronic-phase chronic myeloid leukemia patients who achieved major molecular response with detectable levels of BCR-ABL1 transcripts by imatinib therapy. Int J Clin Oncol 2017; 22:972-979. [PMID: 28550414 PMCID: PMC5608785 DOI: 10.1007/s10147-017-1141-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/14/2017] [Indexed: 01/06/2023]
Abstract
Background With the introduction of imatinib, a first-generation tyrosine kinase inhibitor (TKI) to inhibit BCR-ABL1 kinase, the outcome of chronic-phase chronic myeloid leukemia (CP-CML) has improved dramatically. However, only a small proportion of CP-CML patients subsequently achieve a deep molecular response (DMR) with imatinib. Dasatinib, a second-generation TKI, is more potent than imatinib in the inhibition of BCR-ABL1 tyrosine kinase in vitro and more effective in CP-CML patients who do not achieve an optimal response with imatinib treatment. Methods In the present study, we attempted to investigate whether switching the treatment from imatinib to dasatinib can induce DMR in 16 CP-CML patients treated with imatinib for at least two years who achieved a major molecular response (MMR) with detectable levels of BCR-ABL1 transcripts. Results The rates of achievement of DMR at 1, 3, 6 and 12 months after switching to dasatinib treatment in the 16 patients were 44% (7/16), 56% (9/16), 63% (10/16) and 75% (12/16), respectively. The cumulative rate of achieving DMR at 12 months from initiation of dasatinib therapy was 93.8% (15/16). The proportion of natural killer cells and cytotoxic T cells in peripheral lymphocytes increased after switching to dasatinib. In contrast, the proportion of regulatory T cells decreased during treatment. The safety profile of dasatinib was consistent with previous studies. Conclusion Switching to dasatinib would be a therapeutic option for CP-CML patients who achieved MMR but not DMR by imatinib, especially for patients who wish to discontinue TKI therapy.
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Affiliation(s)
- Masayuki Shiseki
- Department of Hematology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Chikashi Yoshida
- Department of Hematology, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Naoki Takezako
- Department of Hematology, National Disaster Medical Center, Tokyo, Japan
| | - Akira Ohwada
- Department of Hematology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takashi Kumagai
- Department of Hematology, Ohme Municipal General Hospital, Tokyo, Japan
| | - Kaichi Nishiwaki
- Clinical Oncology and Hematology, Jikei University Kashiwa Hospital, Chiba, Japan
| | - Akira Horikoshi
- Department of General Internal Medicine, Nerima-Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuya Fukuda
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hina Takano
- Department of Hematology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Yasuji Kouzai
- Hematology Department, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Division of Hematology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
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Gullaksen SE, Skavland J, Gavasso S, Tosevski V, Warzocha K, Dumrese C, Ferrant A, Gedde-Dahl T, Hellmann A, Janssen J, Labar B, Lang A, Majeed W, Mihaylov G, Stentoft J, Stenke L, Thaler J, Thielen N, Verhoef G, Voglova J, Ossenkoppele G, Hochhaus A, Hjorth-Hansen H, Mustjoki S, Sopper S, Giles F, Porkka K, Wolf D, Gjertsen BT. Single cell immune profiling by mass cytometry of newly diagnosed chronic phase chronic myeloid leukemia treated with nilotinib. Haematologica 2017; 102:1361-1367. [PMID: 28522574 PMCID: PMC5541871 DOI: 10.3324/haematol.2017.167080] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/08/2017] [Indexed: 12/27/2022] Open
Abstract
Monitoring of single cell signal transduction in leukemic cellular subsets has been proposed to provide deeper understanding of disease biology and prognosis, but has so far not been tested in a clinical trial of targeted therapy. We developed a complete mass cytometry analysis pipeline for characterization of intracellular signal transduction patterns in the major leukocyte subsets of chronic phase chronic myeloid leukemia. Changes in phosphorylated Bcr-Abl1 and the signaling pathways involved were readily identifiable in peripheral blood single cells already within three hours of the patient receiving oral nilotinib. The signal transduction profiles of healthy donors were clearly distinct from those of the patients at diagnosis. Furthermore, using principal component analysis, we could show that phosphorylated transcription factors STAT3 (Y705) and CREB (S133) within seven days reflected BCR-ABL1IS at three and six months. Analyses of peripheral blood cells longitudinally collected from patients in the ENEST1st clinical trial showed that single cell mass cytometry appears to be highly suitable for future investigations addressing tyrosine kinase inhibitor dosing and effect. (clinicaltrials.gov identifier: 01061177)
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Affiliation(s)
- Stein-Erik Gullaksen
- Centre of Cancer Biomarkers CCBIO, Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Norway
| | - Jørn Skavland
- Centre of Cancer Biomarkers CCBIO, Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Norway
| | - Sonia Gavasso
- Department of Clinical Medicine, University of Bergen, Norway.,Neuroimmunology Lab, Haukeland University Hospital, Bergen, Norway
| | - Vinko Tosevski
- Mass Cytometry Facility, University of Zurich, Switzerland
| | - Krzysztof Warzocha
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Augustin Ferrant
- Hematology Department, Cliniques Universitaires St Luc, Brussels, Belgium
| | | | | | - Jeroen Janssen
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Boris Labar
- Department of Hematology, University Hospital Center Rebro, Zagreb, Croatia
| | - Alois Lang
- Internal Medicine, Hospital Feldkirch, Austria
| | - Waleed Majeed
- Department of Hemato-Oncology, Stavanger University Hospital, Norway
| | | | | | - Leif Stenke
- Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Josef Thaler
- Department of Internal Medicine IV, Wels-Grieskirchen Hospital, Wels, Austria
| | - Noortje Thielen
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Gregor Verhoef
- Department of Hematology, University Hospital Leuven, Belgium
| | - Jaroslava Voglova
- 4 Department of Internal Medicine - Hematology, University Hospital Hradec Kralove, Czech Republic
| | - Gert Ossenkoppele
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Andreas Hochhaus
- Department of Hematology and Medical Oncology, Universitätsklinikum Jena, Germany
| | - Henrik Hjorth-Hansen
- Department of Hematology, St Olavs Hospital, Trondheim, Norway.,IKM, NTNU, Trondheim, Norway
| | - Satu Mustjoki
- Hematology Research Unit Helsinki, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Finland.,Department of Clinical Chemistry, University of Helsinki, Finland
| | - Sieghart Sopper
- Department of Hematology and Oncology, Innsbruck Medical University and Tyrolean Cancer Research Institute, Innsbruck, Austria
| | - Francis Giles
- NMDTI, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Kimmo Porkka
- Hematology Research Unit Helsinki, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Finland
| | - Dominik Wolf
- Department of Hematology and Oncology, Innsbruck Medical University and Tyrolean Cancer Research Institute, Innsbruck, Austria.,Medical Clinic 3, Oncology, Hematology and Rheumatology, University Hospital Bonn (UKB), Germany
| | - Bjørn Tore Gjertsen
- Centre of Cancer Biomarkers CCBIO, Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Norway .,Department of Internal Medicine, Haukeland University Hospital, Bergen, Norway
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Sopper S, Mustjoki S, White D, Hughes T, Valent P, Burchert A, Gjertsen BT, Gastl G, Baldauf M, Trajanoski Z, Giles F, Hochhaus A, Ernst T, Schenk T, Janssen JJ, Ossenkoppele GJ, Porkka K, Wolf D. Reduced CD62L Expression on T Cells and Increased Soluble CD62L Levels Predict Molecular Response to Tyrosine Kinase Inhibitor Therapy in Early Chronic-Phase Chronic Myelogenous Leukemia. J Clin Oncol 2017; 35:175-184. [DOI: 10.1200/jco.2016.67.0893] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Purpose Immunologic surveillance of minimal residual disease in chronic myelogenous leukemia (CML) may be relevant for long-term control or cure of CML. Little is known about immune-modulatory effects of nilotinib in vivo, potentially predicting response to therapy. Patients and Methods A prospective and comprehensive flow cytometry–based immunomonitoring program paralleled the ENEST1st clinical study, investigating 52 nilotinib-naïve patients with chronic-phase CML. Data were verified in independent validation cohorts. Results T cells of patients with CML at diagnosis expressed low l-selectin (CD62L) levels, which was not a result of proportional aberrations of T-cell subsets. Low numbers of CD62L-expressing CD4+ and CD8+ T cells correlated with higher Sokal score, increased spleen size, and high leukocyte and peripheral-blood blast counts. At month 6 during nilotinib therapy, CD62L expression returned to levels of healthy individuals. The level of CD62L loss on T cells directly correlated with the extent of soluble CD62L (sCD62L) elevation. In parallel, the proteolytic activity of tumor necrosis factor α–converting enzyme (TACE; ADAM17, CD156b), the metalloproteinase shedding CD62L, was increased at diagnosis and significantly decreased during nilotinib treatment. High CD62L+ expression on both CD4+ and CD8+ T cells and, vice versa, low sCD62L levels at CML diagnosis were linked to superior molecular responses. These findings were corroborated in independent validation cohorts. Conclusion We demonstrate the prognostic impact of CD62L shedding from T cells and increased sCD62L plasma levels at CML diagnosis on molecular response to tyrosine kinase inhibitor therapy in early chronic-phase CML. Functionally, decreased CD62L may be a consequence of increased TACE-mediated CD62L cleavage and potentially impairs immune-cell function. Larger prospective studies are ongoing to confirm the prognostic relevance of this finding.
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Affiliation(s)
- Sieghart Sopper
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Satu Mustjoki
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Deborah White
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Timothy Hughes
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Peter Valent
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Andreas Burchert
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Bjørn T. Gjertsen
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Günther Gastl
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Matthias Baldauf
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Zlatko Trajanoski
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Frank Giles
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Andreas Hochhaus
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Thomas Ernst
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Thomas Schenk
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Jeroen J.W.M. Janssen
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Gert J. Ossenkoppele
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Kimmo Porkka
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
| | - Dominik Wolf
- Sieghart Sopper, Günther Gastl, Matthias Baldauf, Zlatko Trajanoski, and Dominik Wolf, Medical University Innsbruck; Sieghart Sopper and Dominik Wolf, Tyrolean Cancer Research Institute; Matthias Baldauf, Oncotyrol, Innsbruck; Peter Valent, Medical University of Vienna, Vienna, Austria; Satu Mustjoki and Kimmo Porkka, University of Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; Deborah White and Timothy Hughes, South Australian Health and Medical Research
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13
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Iriyama N, Hatta Y, Takei M. Direct effect of dasatinib on signal transduction pathways associated with a rapid mobilization of cytotoxic lymphocytes. Cancer Med 2016; 5:3223-3234. [PMID: 27726309 PMCID: PMC5119978 DOI: 10.1002/cam4.925] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/06/2016] [Accepted: 09/04/2016] [Indexed: 01/04/2023] Open
Abstract
It has been shown that an increase in cytotoxic lymphocyte counts in the peripheral blood occurs rapidly after taking dasatinib, but the underlying mechanism is not yet elucidated. To investigate the influence of dasatinib on signal transduction pathways, we investigated the changes in JAK-STAT, mitogen-activated protein kinase (MAPK), and AKT in cytotoxic lymphocytes, including natural killer (NK) cells and cytotoxic T lymphocytes (CTLs), before and after dasatinib treatment in chronic myeloid leukemia patients. Among a total of 30 patients, 18 were treated with dasatinib, nine with imatinib, and three with nilotinib. At constitutive levels, the expression of phosphorylated proteins, pSTAT1, pSTAT3, and pERK in NK cells and pSTAT3 in CTLs, was significantly higher in dasatinib-treated patients. Among the patients evaluated, only dasatinib-treated patients showed inhibition of multiple signaling pathways after taking a tyrosine kinase inhibitor. The magnitude of pERK and pAKT inhibition was closely associated with an increase in NK cells and CTLs, respectively, after taking a tyrosine kinase inhibitor. Those responses were more evident in patients with cytomegalovirus IgG positivity. In this study, we demonstrated for the first time, the influence of dasatinib on cell events in cytotoxic lymphocytes in vivo and explained the possible underlying mechanism that results in lymphocyte mobilization after dasatinib treatment.
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Affiliation(s)
- Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshihiro Hatta
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masami Takei
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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14
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Hagihara M, Iriyama N, Yoshida C, Wakita H, Chiba S, Okamoto S, Kawakami K, Takezako N, Kumagai T, Inokuchi K, Ohyashiki K, Taguchi J, Yano S, Igarashi T, Kouzai Y, Morita S, Sakamoto J, Sakamaki H. Association of pleural effusion with an early molecular response in patients with newly diagnosed chronic-phase chronic myeloid leukemia receiving dasatinib: Results of a D-First study. Oncol Rep 2016; 36:2976-2982. [PMID: 27665844 DOI: 10.3892/or.2016.5110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 09/07/2016] [Indexed: 11/06/2022] Open
Abstract
Despite the efficacy and safety of dasatinib treatment for chronic-phase chronic myeloid leukemia (CML-CP), adverse effects such as pleural effusion (PE) are still a serious concern. We determined the clinical significance of PE incidence using patient data derived from the D-First clinical study. In the present study, chest radiography and quantification of specific lymphocyte subsets were performed routinely after initiation of dasatinib treatment. Among 52 patients with newly diagnosed CML-CP, 17 (33%) developed PE within 18 months after initial dasatinib administration, but all cases were moderate (Grade 1, 10 patients; Grade 2, 7 patients). CD56+ lymphocyte counts at 1 month correlated significantly with the incidence of PE, whereas lymphocytosis did not. The major molecular response (MMR) rate at 3 months (although not at later times) was significantly higher in PE-positive patients than PE-negative patients (59% versus 24%, respectively; P=0.013). Deep molecular response rates did not differ significantly between the PE groups at any time point during the observation period. Our results suggest that an immune-mediated mechanism involving natural killer cells underlies the development of PE in patients receiving dasatinib for 18 months. This mechanism likely promotes transient tumor regression in patients newly diagnosed with CML-CP.
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Affiliation(s)
- Maki Hagihara
- Department of Hematology, Yokohama City University Medical Center, Kanagawa, Japan
| | - Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Chikashi Yoshida
- Department of Hematology, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Society, Narita Red Cross Hospital, Chiba, Japan
| | - Shigeru Chiba
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kimihiro Kawakami
- Department of Hematology and Clinical Oncology, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Takashi Kumagai
- Department of Hematology, Ohme Municipal General Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Division of Hematology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jun Taguchi
- Department of Hematology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Tadahiko Igarashi
- Division of Hematology and Oncology, Gunma Prefectural Cancer Center, Gunma, Japan
| | - Yasuji Kouzai
- Department of Hematology, Tokyo Metropolitan Tama Synthesis Medical Center, Tokyo, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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15
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Galluzzi L, Buqué A, Kepp O, Zitvogel L, Kroemer G. Immunological Effects of Conventional Chemotherapy and Targeted Anticancer Agents. Cancer Cell 2015; 28:690-714. [PMID: 26678337 DOI: 10.1016/j.ccell.2015.10.012] [Citation(s) in RCA: 1094] [Impact Index Per Article: 121.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/05/2015] [Accepted: 10/23/2015] [Indexed: 11/23/2022]
Abstract
The tremendous clinical success of checkpoint blockers illustrates the potential of reestablishing latent immunosurveillance for cancer therapy. Although largely neglected in the clinical practice, accumulating evidence indicates that the efficacy of conventional and targeted anticancer agents does not only involve direct cytostatic/cytotoxic effects, but also relies on the (re)activation of tumor-targeting immune responses. Chemotherapy can promote such responses by increasing the immunogenicity of malignant cells, or by inhibiting immunosuppressive circuitries that are established by developing neoplasms. These immunological "side" effects of chemotherapy are desirable, and their in-depth comprehension will facilitate the design of novel combinatorial regimens with improved clinical efficacy.
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Affiliation(s)
- Lorenzo Galluzzi
- Equipe 11 Labellisée Ligue contre le Cancer, Centre de Recherche des Cordeliers, 75006 Paris, France; INSERM, U1138, 75006 Paris, France; Université Paris Descartes/Paris V, Sorbonne Paris Cité, 75006 Paris, France; Université Pierre et Marie Curie/Paris VI, 75006 Paris, France; Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
| | - Aitziber Buqué
- Equipe 11 Labellisée Ligue contre le Cancer, Centre de Recherche des Cordeliers, 75006 Paris, France; INSERM, U1138, 75006 Paris, France; Université Paris Descartes/Paris V, Sorbonne Paris Cité, 75006 Paris, France; Université Pierre et Marie Curie/Paris VI, 75006 Paris, France; Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
| | - Oliver Kepp
- Equipe 11 Labellisée Ligue contre le Cancer, Centre de Recherche des Cordeliers, 75006 Paris, France; INSERM, U1138, 75006 Paris, France; Université Paris Descartes/Paris V, Sorbonne Paris Cité, 75006 Paris, France; Université Pierre et Marie Curie/Paris VI, 75006 Paris, France; Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
| | - Laurence Zitvogel
- Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France; INSERM, U1015, 94805 Villejuif, France; Center of Clinical Investigations in Biotherapies of Cancer (CICBT) 507, 94805 Villejuif, France; Université Paris Sud/Paris XI, 94270 Le Kremlin-Bicêtre, France.
| | - Guido Kroemer
- Equipe 11 Labellisée Ligue contre le Cancer, Centre de Recherche des Cordeliers, 75006 Paris, France; INSERM, U1138, 75006 Paris, France; Université Paris Descartes/Paris V, Sorbonne Paris Cité, 75006 Paris, France; Université Pierre et Marie Curie/Paris VI, 75006 Paris, France; Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France; Pôle de Biologie, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France; Karolinska Institute, Department of Women's and Children's Health, Karolinska University Hospital, 17176 Stockholm, Sweden.
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Discontinuation of dasatinib in patients with chronic myeloid leukaemia who have maintained deep molecular response for longer than 1 year (DADI trial): a multicentre phase 2 trial. LANCET HAEMATOLOGY 2015; 2:e528-35. [PMID: 26686407 DOI: 10.1016/s2352-3026(15)00196-9] [Citation(s) in RCA: 238] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND First-line imatinib treatment can be successfully discontinued in patients with chronic myeloid leukaemia after deep molecular response has been sustained for at least 2 years. We investigated the safety and efficacy of discontinuing second-line or subsequent dasatinib after at least 1 year of deep molecular response. METHODS The Dasatinib Discontinuation trial was a prospective multicentre trial done in Japan. Eligible patients taking dasatinib and with confirmed stable deep molecular response were enrolled between April 1, 2011, and March 31, 2012. All patients received dasatinib consolidation therapy for at least 1 year. In those with sustained deep molecular response, dasatinib was discontinued. Patients were followed up every month in year 1 (clinical cutoff), every 3 months in year 2, and every 6 months in year 3 for deep molecular response and immunological profiles. The primary endpoint was the proportion of patients with treatment-free remission at 6 months after discontinuation. Molecular relapse was defined as loss of deep molecular response at any assessment. This study is registered, number UMIN000005130. FINDINGS 88 patients were enrolled in the consolidation phase, 24 were excluded from the discontinuation phase due to fluctuations in BCR-ABL1 transcript levels. One patient was excluded because of positive expression of major and minor BCR-ABL1 transcripts in chronic myeloid leukaemia cells and the detection of minor BCR-ABL1 transcripts during consolidation. Thus, 63 patients discontinued dasatinib treatment. The 25 patients who were excluded from discontinuation continued to receive dasatinib and none showed disease progression. Median follow-up was 20.0 months (IQR 16.5-24.0). Of the 63 patients who discontinued and were not excluded, 30 patients maintained deep molecular response while 33 patients had molecular relapses, all within the first 7 months after discontinuation. The estimated overall treatment-free remission was 49% (95% CI 36-61) at 6 months. No severe treatment-related toxic effects were seen. Treatment was restarted in the 33 patients with relapse; rapid molecular responses were seen in all 33 patients, of whom 29 (88%) regained deep molecular response within 3 months, as did the remaining four by 6 months. INTERPRETATION Dasatinib discontinuation after sustained deep molecular response for more than 1 year is feasible. FUNDING Epidemiological and Clinical Research Information Network (ECRIN).
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17
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Iriyama N, Fujisawa S, Yoshida C, Wakita H, Chiba S, Okamoto S, Kawakami K, Takezako N, Kumagai T, Inokuchi K, Ohyashiki K, Taguchi J, Yano S, Igarashi T, Kouzai Y, Morita S, Sakamoto J, Sakamaki H. Early cytotoxic lymphocyte expansion contributes to a deep molecular response to dasatinib in patients with newly diagnosed chronic myeloid leukemia in the chronic phase: results of the D-first study. Am J Hematol 2015; 90:819-24. [PMID: 26103598 DOI: 10.1002/ajh.24096] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 01/24/2023]
Abstract
Dasatinib is one of the key treatment options for chronic myeloid leukemia (CML) patients. Increase in lymphocyte counts has been known to be predictive of a good treatment response under dasatinib treatment as a second line therapy. However, clinical significance of lymphocyte dynamics in the upfront setting has yet to be clarified. To investigate the significance of lymphocyte dynamics in newly diagnosed chronic phase (CP)-CML, patient data of D-First study (ClinicalTrials.gov NCT01464411) were analyzed. Fifty-two CML-CP patients enrolled to this study were treated with dasatinib (100 mg day(-1) ) and all were followed-up for 18 months. The incidence of lymphocyosis was observed in 14 (27%), but it was not associated with deep molecular response achievement. However, natural killer (NK) cell or cytotoxic T lymphocyte (CTL) counts at 1 month were significantly higher in patients with deep molecular response (DMR) by 18 months compared to those without DMR. When the patients were divided into two groups according to those calculated thresholds by receiver operating characteristic curve (407/μL for NK cells and 347/μL for CTLs), the cumulative DMR rates by 18 months were significantly better in higher value group compared to lower value group. In contrast, regulatory T cell counts were significantly lower at 12 and 15 months in patients achieved DMR. These results suggest the presence of dual effects of dasatinib on immune system through the cytotoxic lymphocytes activation and Treg deregulation in different periods in newly diagnosed CML-CP.
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MESH Headings
- Antigens, CD/genetics
- Antigens, CD/immunology
- Antineoplastic Agents/therapeutic use
- Dasatinib
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/immunology
- Gene Expression
- Humans
- Immunophenotyping
- Killer Cells, Natural/drug effects
- Killer Cells, Natural/immunology
- Killer Cells, Natural/pathology
- Leukemia, Myeloid, Chronic-Phase/drug therapy
- Leukemia, Myeloid, Chronic-Phase/genetics
- Leukemia, Myeloid, Chronic-Phase/immunology
- Leukemia, Myeloid, Chronic-Phase/pathology
- Lymphocyte Count
- Lymphocytosis/chemically induced
- Lymphocytosis/genetics
- Lymphocytosis/immunology
- Lymphocytosis/pathology
- Prospective Studies
- Protein Kinase Inhibitors/therapeutic use
- Pyrimidines/therapeutic use
- ROC Curve
- Remission Induction
- T-Lymphocytes, Cytotoxic/drug effects
- T-Lymphocytes, Cytotoxic/immunology
- T-Lymphocytes, Cytotoxic/pathology
- T-Lymphocytes, Regulatory/drug effects
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/pathology
- Thiazoles/therapeutic use
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Affiliation(s)
- Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, Kanagawa, Japan
| | - Chikashi Yoshida
- Department of Hematology, National Hospital Organization, Mito Medical Center, Ibaraki, Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Society, Narita Red Cross Hospital, Narita, Japan
| | - Shigeru Chiba
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kimihiro Kawakami
- Department of Hematology and Clinical Oncology, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Takashi Kumagai
- Department of Hematology, Ohme Municipal General Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Division of Hematology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jun Taguchi
- Department of Hematology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Tadahiko Igarashi
- Division of Hematology and Oncology, Gunma Prefectural Cancer Center, Gunma, Japan
| | - Yasuji Kouzai
- Department of Hematology, Tokyo Metropolitan Tama Synthesis Medical Center, Tokyo, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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Inokuchi K, Kumagai T, Matsuki E, Ohashi K, Shinagawa A, Hatta Y, Takeuchi J, Yoshida C, Wakita H, Kozai Y, Shirasugi Y, Fujisawa S, Iwase O, Yano S, Okamoto S, Oba K, Sakamoto J, Sakamaki H. Efficacy of molecular response at 1 or 3 months after the initiation of dasatinib treatment can predict an improved response to dasatinib in imatinib-resistant or imatinib-intolerant Japanese patients with chronic myelogenous leukemia during the chronic phase. J Clin Exp Hematop 2015; 54:197-204. [PMID: 25501110 DOI: 10.3960/jslrt.54.197] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Dasatinib is a BCR-ABL kinase inhibitor with improved potency compared with imatinib, for which efficacy and safety in imatinib-resistant and imatinib-intolerant patients with chronic myelogenous leukemia (CML) have been established. Here, an open-label phase II study evaluated the efficacy and safety of dasatinib in 50 Japanese patients with imatinib-resistant or imatinib-intolerant CML during the chronic phase (CML-CP). Dasatinib was effective in imatinib-resistant and imatinib-intolerant patients. After 12 months of dasatinib therapy, 35 patients (70%) had achieved a major molecular response (MMR) and 16 patients (32%) had achieved a complete molecular response (CMR). Among the imatinib-resistant CML-CP cohort, 21 and 8 patients had achieved an MMR and a CMR after 12 months of dasatinib therapy, respectively. Among the imatinib-intolerant CML-CP cohort, 14 and 8 patients had achieved an MMR and a CMR after 12 months of dasatinib therapy, respectively. After 18 months of dasatinib therapy, 38 out of 50 patients (76.0%) had achieved an MMR and 19 patients (38.0%) had achieved a CMR. A lower level of BCR-ABL transcript at 1 or 3 months after the initiation of dasatinib treatment was more strongly correlated with the BCR-ABL transcript level at 12 and 18 months (p < 0.001) than a higher level of BCR-ABL. The T315I mutation was identified in two patients receiving dasatinib therapy. Dasatinib was generally well tolerated, with only 3 patients (5%) having treatment discontinuation as a result of adverse hematologic events (thrombocytopenia, anemia, neutropenia) and/or non-hematologic events at a 12-month follow-up evaluation. Dasatinib was a safe and effective treatment for Japanese patients with imatinib-resistant or imatinib-intolerant CML. In addition, the molecular response at 1 or 3 months predicted a response to dasatinib at 12 or 18 months.
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Affiliation(s)
- Koiti Inokuchi
- Division of Hematology, Department of Internal Medicine, Nippon Medical School
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Shimura Y, Horiike S, Tsutsumi Y, Hatsuse M, Okano A, Fuchida SI, Kobayashi T, Matsumoto Y, Kuroda J, Kawata-Iida E, Uchiyama H, Uoshima N, Shimazaki C, Kaneko H, Kobayashi Y, Taniwaki M. The longitudinal analysis of large granular lymphocytosis in patients with Philadelphia chromosome-positive leukemia treated with dasatinib. Int J Hematol 2015; 102:426-33. [PMID: 26267232 DOI: 10.1007/s12185-015-1848-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 11/29/2022]
Abstract
Dasatinib, a 2nd-generation tyrosine kinase inhibitor (TKI), can specifically induce large granular lymphocytes (LGL) in some patients with Philadelphia chromosome (Ph)-positive leukemia. To investigate the properties of the induced LGLs, we performed prospective and longitudinal analyses. From Feb 2011 to Jan 2013, a total of 17 patients with Ph-positive leukemia who were previously untreated or refractory to imatinib were enrolled. T cell receptor (TCR)-γ/δ gene rearrangements and phenotypic profiles of lymphocytes were examined before and during administration of dasatinib. LGL lymphocytosis was observed in half of the dasatinib-treated cases (LGL+ group), showing a relation to increased achievement of complete cytogenetic response within 6 months. The phenotypes of the increased lymphocytes were revealed to be mostly natural killer cells. In the LGL+ group, clonal TCR-γ gene rearrangements were frequently detected at diagnosis (six of nine cases) and persisted during therapy, compared with only two of eight in the LGL- group. The proportion of regulatory T cells to CD4+ T cells at diagnosis was lower in the LGL+ compared with the LGL- group (median 4.2 vs. 6.6 %), and this disparity was sustained throughout the therapeutic period. These results demonstrate that immunological condition at diagnosis may affect LGL lymphocytosis in some dasatinib-treated patients.
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Affiliation(s)
- Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Shigeo Horiike
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.,Department of Blood Transfusion and Cell Therapy, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuhiko Tsutsumi
- Division of Hematology, Department of Medicine, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Mayumi Hatsuse
- Division of Hematology, Department of Medicine, Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Akira Okano
- Division of Hematology, Department of Medicine, Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Shin-Ichi Fuchida
- Division of Hematology, Department of Medicine, Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Yosuke Matsumoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Eri Kawata-Iida
- Division of Hematology, Department of Medicine, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Hitoji Uchiyama
- Division of Hematology, Department of Medicine, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Nobuhiko Uoshima
- Division of Hematology, Department of Medicine, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Chihiro Shimazaki
- Division of Hematology, Department of Medicine, Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Hiroto Kaneko
- Division of Hematology, Department of Medicine, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Yutaka Kobayashi
- Division of Hematology, Department of Medicine, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Masafumi Taniwaki
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
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20
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Iriyama N, Fujisawa S, Yoshida C, Wakita H, Chiba S, Okamoto S, Kawakami K, Takezako N, Kumagai T, Inokuchi K, Ohyashiki K, Taguchi J, Yano S, Igarashi T, Kouzai Y, Morita S, Sakamoto J, Sakamaki H. Shorter halving time of BCR-ABL1 transcripts is a novel predictor for achievement of molecular responses in newly diagnosed chronic-phase chronic myeloid leukemia treated with dasatinib: Results of the D-first study of Kanto CML study group. Am J Hematol 2015; 90:282-7. [PMID: 25530131 DOI: 10.1002/ajh.23923] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 01/28/2023]
Abstract
To investigate the factors that affect molecular responses on dasatinib treatment in patients with chronic-phase chronic myeloid leukemia (CML-CP), we performed a clinical trial named the "D-First study." Fifty-two patients with newly diagnosed CML-CP were enrolled in this study and received 100 mg dasatinib once daily. A deep molecular response (DMR) was defined as <50 copies/μg RNA of BCR-ABL1 transcript value corrected by GAPDH, which ensures <0.01% of BCR-ABL1 transcript value according to International Scale (BCR-ABL1(IS)). The halving time for BCR-ABL1 transcripts was calculated using transcript levels before dasatinib treatment, transcript levels after 3 months of treatment, and the treatment time between these two points. In terms of molecular response, 38 of 51 (75%) patients reached major molecular response (MMR) by 12 months, and the rate of DMR by 18 months was 59% (30/51). While both BCR-ABL1 transcript levels before treatment and a shorter halving time of BCR-ABL1 transcripts (≤14 days) were significant factors affecting achievement of MMR by 12 months, the Sokal score at diagnosis was not associated with MMR. Importantly, the halving time was the only factor that predicted achievement of DMR by 18 months. We showed that patients with CML-CP treated with dasatinib can be stratified according to the early treatment response as determined by the halving time of BCR-ABL1 transcripts. These data emphasize the significance of the early response from dasatinib treatment in achieving a DMR. (ClinicalTrials.gov; NCT01464411).
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Affiliation(s)
- Noriyoshi Iriyama
- Division of Hematology and Rheumatology; Department of Medicine; Nihon University School of Medicine; Tokyo Japan
| | - Shin Fujisawa
- Department of Hematology; Yokohama City University Medical Center; Kanagawa Japan
| | - Chikashi Yoshida
- Department of Hematology; National Hospital Organization Mito Medical Center; Ibaraki Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology; Japanese Red Cross Society, Narita Red Cross Hospital; Narita Japan
| | - Shigeru Chiba
- Department of Hematology; Faculty of Medicine; University of Tsukuba; Ibaraki Japan
| | - Shinichiro Okamoto
- Division of Hematology; Department of Internal Medicine; Keio University School of Medicine; Tokyo Japan
| | - Kimihiro Kawakami
- Department of Hematology and Clinical Oncology; Kagawa Prefectural Central Hospital; Kagawa Japan
| | - Naoki Takezako
- Department of Hematology; National Hospital Organization Disaster Medical Center; Tokyo Japan
| | - Takashi Kumagai
- Department of Hematology; Ohme Municipal General Hospital; Tokyo Japan
| | - Koiti Inokuchi
- Division of Hematology; Department of Internal Medicine; Nippon Medical School; Tokyo Japan
| | | | - Jun Taguchi
- Department of Hematology; Japanese Red Cross Shizuoka Hospital; Shizuoka Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology; Department of Internal Medicine; Jikei University School of Medicine; Tokyo Japan
| | - Tadahiko Igarashi
- Division of Hematology and Oncology; Gunma Prefectural Cancer Center; Gunma Japan
| | - Yasuji Kouzai
- Department of Hematology; Tokyo Metropolitan Tama Synthesis Medical Center; Tokyo Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | | | - Hisashi Sakamaki
- Hematology Division; Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital; Tokyo Japan
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