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Nishiyama-Fujita Y, Nakazato T, Iriyama N, Tokuhira M, Ishikawa M, Sato E, Takaku T, Sugimoto K, Fujita H, Fujioka I, Tsuchiya S, Kimura Y, Iwanaga E, Komatsu N, Asou N, Kizaki M, Hatta Y, Kawaguchi T. Outcomes of adolescents and young adults with chronic-phase chronic myeloid leukaemia treated with tyrosine kinase inhibitors. Ann Med 2022; 54:1244-1254. [PMID: 35486442 PMCID: PMC9126594 DOI: 10.1080/07853890.2022.2069280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Few studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs). MATERIALS AND METHODS We retrospectively analysed the clinical features, treatment response, and long-term outcomes of 42 AYA patients, in comparison to older patients. The initial therapies of AYA patients between 2001 and 2016 included imatinib (n = 24), dasatinib (n = 13) and nilotinib (n = 5). RESULTS In AYA patients, the peripheral blood (PB) white blood cell count and percentage of blasts at the diagnosis were significantly higher, haemoglobin levels were lower and the spleen size was larger. The major molecular response (MMR), event-free survival (EFS) and overall survival (OS) rates were comparable. A sub-analysis comparing imatinib to second-generation TKIs as the initial therapy also showed that their prognosis was comparable. DISCUSSION In conclusion, the tumour burden at the diagnosis of CML-CP is higher in AYA patients; however, their prognosis was not worse in comparison to older patients treated with TKIs. KEY MESSAGESFew studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs). This study showed the tumour burden at the diagnosis of CML-CP is higher in AYA pa tients; however, their prognosis was not worse in comparison to older patients treated with TKIs. Understanding the biological and non-biological features of AYA patients with CML-CP on TKI therapy is essential for better management and to improve the outcomes.
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Affiliation(s)
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Noriyoshi Iriyama
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Maho Ishikawa
- Department of Hemato-Oncology, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Eriko Sato
- Department of Hematology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomoiku Takaku
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keiji Sugimoto
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Isao Fujioka
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shun Tsuchiya
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuta Kimura
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Eisaku Iwanaga
- Department of Hematology, Kumamoto University Hospital, Kumamoto, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Asou
- Department of Hemato-Oncology, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshihiro Hatta
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuya Kawaguchi
- Medical Technology, Kumamoto Health Science University, Kumamoto, Japan
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Bedewy AML, Elmaghraby SM, Kandil NS. ABCB1 and BMI1 mRNA expression in patients with chronic myeloid leukemia: impact on imatinib efficacy. Blood Res 2019; 54:57-62. [PMID: 30956965 PMCID: PMC6439291 DOI: 10.5045/br.2019.54.1.57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/29/2018] [Accepted: 10/22/2018] [Indexed: 12/16/2022] Open
Abstract
Background ATP-binding cassette transporters are important in the mechanism of multidrug resistance. ABCB1 displays a high affinity for imatinib. BMI1 is a polycomb group protein thought to be overexpressed in leukemic cells. Methods This study was conducted to investigate the prognostic value of ABCB1 and BMI1 expressions in chronic myeloid leukemia (CML). Expression levels were measured in 81 patients newly diagnosed with CML and 20 healthy controls by real time reverse transcription- PCR. Results The ABCB1 expression levels did not differ between patients with CML and controls. Low ABCB1 mRNA levels were observed in patients who achieved an optimal response compared to suboptimal and resistant cases (P=0.005). Non-responders showed the highest ABCB1 levels. ABCB1 expression did not affect the progression-free survival (PFS) of patients. BMI1 expression was higher in patients than that in controls (P=0.001). Patients in advanced phases expressed higher levels of BMI1 than those in the chronic phase (P=0.004). High BMI1 expression was associated with a shorter PFS. Conclusion ABCB1 mRNA expression may serve as a predictor of the optimal response to imatinib treatment in patients with CML. BMI1 expression was higher in the accelerated and blastic crisis phases of CML and associated with a shorter PFS.
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Affiliation(s)
- Ahmed M L Bedewy
- Hematology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Shereen M Elmaghraby
- Hematology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Noha S Kandil
- Chemical Pathology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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de Bruijn CMA, Millot F, Suttorp M, Borisevich M, Brons P, Lausen B, de Bont ESJM. Discontinuation of imatinib in children with chronic myeloid leukaemia in sustained deep molecular remission: results of the STOP IMAPED study. Br J Haematol 2019; 185:718-724. [PMID: 30843196 DOI: 10.1111/bjh.15826] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 01/04/2019] [Indexed: 12/15/2022]
Abstract
This international study aimed to assess the effect of imatinib discontinuation in paediatric patients with chronic myeloid leukaemia (CML) after deep molecular remission (DMR) had been achieved and maintained for at least 2 years. The primary endpoint of this analysis was the molecular relapse-free survival, estimated by the non-parametric Kaplan-Meier method. Major endpoint was the estimated rate of patients without molecular relapse at 6 months. Fourteen patients were enrolled; 4 patients maintained DMR with a follow-up of 24 (two patients), 34 and 66 months, respectively, whereas 10 patients relapsed. All molecular relapses occurred within 6 months (median 3 months, range 1-6) after imatinib discontinuation. The overall probability of maintaining DMR at 6 months was 28·6%. No parameters associated with molecular relapse could be identified. Keeping in mind the rarity of paediatric CML, which contributed to the small size of the cohort, our findings illustrate that imatinib cessation after sustained DMR is successful in only limited numbers of patients, whereas much higher rates are reported in adult patients. Further research is needed to extend the cohort of paediatric CML patients who might achieve treatment-free remission with an ideal prerequisite of predicting the occurrence of molecular relapse l after imatinib cessation.
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Affiliation(s)
- Clara M A de Bruijn
- Departments of Paediatric Oncology/Haematology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Frédéric Millot
- Departments of Paediatric Oncology/Haematology, Poitiers University Hospital, Poitiers, France
| | - Meinolf Suttorp
- Paediatric Haemato-Oncology, Medical Faculty, Technical University, Dresden, Germany
| | - Marina Borisevich
- Belarusian Research Centre for Paediatric Oncology, Haematology and Immunology, Minsk, Belarus
| | - Paul Brons
- Departments of Paediatric Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Eveline S J M de Bont
- Departments of Paediatric Oncology/Haematology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Mat Yusoff Y, Abu Seman Z, Othman N, Kamaluddin NR, Esa E, Zulkiply NA, Abdullah J, Zakaria Z. Prevalence of BCR-ABL T315I Mutation in Malaysian Patients with Imatinib-Resistant Chronic Myeloid Leukemia. Asian Pac J Cancer Prev 2018; 19:3317-3320. [PMID: 30583336 PMCID: PMC6428553 DOI: 10.31557/apjcp.2018.19.12.3317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Chronic Myeloid Leukemia (CML) is caused by a reciprocal translocation between chromosomes 9 and 22, t(9;22) (q34;q11) which encodes for the BCR-ABL fusion protein. Discovery of Imatinib Mesylate (IM) as first line therapy has brought tremendous improvement in the management of CML. However, emergence of point mutations within the BCR-ABL gene particularly T315I mutation, affects a common BCR-ABL kinase contact residue which impairs drug binding thus contribute to treatment resistance. This study aims to investigate the BCR-ABL T315I mutation in Malaysian patients with CML. Methods: A total of 285 patients diagnosed with CML were included in this study. Mutation detection was performed using qualitative real-time PCR (qPCR). Results: Fifteen out of 285 samples (5.26%) were positive for T315I mutations after amplification with real-time PCR assay. From the total number of positive samples, six patients were in accelerated phase (AP), four in chronic phase (CP) and five in blast crisis (BC). Conclusion: Mutation testing is recommended for choosing various tyrosine kinase inhibitors (TKIs) to optimize outcomes for both cases of treatment failure or suboptimal response to imatinib. Therefore, detection of T315I mutation in CML patients are clinically useful in the selection of appropriate treatment strategies to prevent disease progression.
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Affiliation(s)
- Yuslina Mat Yusoff
- Haematology Unit, Cancer Research Centre, Institute for Medical Research, Jalan Pahang, Wilayah Persekutuan Kuala Lumpur, Malaysia.
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5
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Analysis of ABL kinase domain mutations as a probable cause of imatinib resistance in Chronic Myeloid Leukemia patients of Kashmir. Meta Gene 2018. [DOI: 10.1016/j.mgene.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chauhan R, Sazawal S, Pati HP. Laboratory Monitoring of Chronic Myeloid Leukemia in Patients on Tyrosine Kinase Inhibitors. Indian J Hematol Blood Transfus 2018; 34:197-203. [PMID: 29622860 PMCID: PMC5885003 DOI: 10.1007/s12288-018-0933-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm characterized by translocation of genetic material from chromosome 9 to chromosome 22 to form a fusion gene (BCR-ABL1) that is responsible for abnormal tyrosine kinase activity and alteration of various downstream signaling pathways. In addition to morphological diagnosis of CML phase, it is essential to detect BCR-ABL1 fusion by either metaphase cytogenetics or reverse transcriptase polymerase chain reaction that also determines type of mRNA transcript. Once treatment begins, monitoring the response to Tyrosine Kinase Inhibitor (TKI) using standardized techniques and guidelines is important to check for failure of response and thus, plan timely intervention by increasing the dose of TKI or opting for second line TKIs. The goal is to stop evolution of CML to accelerated phase or blast crisis that has poor response to treatment. Also, it is desirable to achieve good outcomes and even treatment free remission in patients of CML on TKI. Thus, molecular monitoring by reverse transcriptase quantitative PCR (RT-qPCR) is done at regular intervals. There are international recommendations and quality control measures to standardize the reporting of fusion gene transcript levels by quantitative PCR (RT-qPCR) in CML to achieve and maintain sensitivity in molecular detection of CML disease burden. Various state-of-the-art molecular techniques have emerged to accurately determine the number of fusion-gene transcript levels. This review highlights various methodologies and their practical implications in management of CML patients on TKI.
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Affiliation(s)
- Richa Chauhan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sudha Sazawal
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - H. P. Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Pinilla-Ibarz J, Sweet KL, Corrales-Yepez GM, Komrokji RS. Role of tyrosine-kinase inhibitors in myeloproliferative neoplasms: comparative lessons learned. Onco Targets Ther 2016; 9:4937-57. [PMID: 27570458 PMCID: PMC4986686 DOI: 10.2147/ott.s102504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
An important pathogenetic distinction in the classification of myeloproliferative neoplasms (MPNs) is the presence or absence of the BCR–ABL fusion gene, which encodes a unique oncogenic tyrosine kinase. The BCR–ABL fusion, caused by the formation of the Philadelphia chromosome (Ph) through translocation, constitutes the disease-initiating event in chronic myeloid leukemia. The development of successive BCR–ABL-targeted tyrosine-kinase inhibitors has led to greatly improved outcomes in patients with chronic myeloid leukemia, including high rates of complete hematologic, cytogenetic, and molecular responses. Such levels of treatment success have long been elusive for patients with Ph-negative MPNs, because of the difficulties in identifying specific driver proteins suitable as drug targets. However, in recent years an improved understanding of the complex pathobiology of classic Ph-negative MPNs, characterized by variable, overlapping multimutation profiles, has prompted the development of better and more broadly targeted (to pathway rather than protein) treatment options, particularly JAK inhibitors. In classic Ph-negative MPNs, overactivation of JAK-dependent signaling pathways is a central pathogenic mechanism, and mutually exclusive mutations in JAK2, MPL, and CALR linked to aberrant JAK activation are now recognized as key drivers of disease progression in myelofibrosis (MF). In clinical trials, the JAK1/JAK2 inhibitor ruxolitinib – the first therapy approved for MF worldwide – improved disease-related splenomegaly and symptoms independent of JAK2V617F mutational status, and prolonged survival compared with placebo or standard therapy in patients with advanced MF. In separate trials, ruxolitinib also provided comprehensive hematologic control in patients with another Ph-negative MPN – polycythemia vera. However, complete cytogenetic or molecular responses with JAK inhibitors alone are normally not observed, underscoring the need for novel combination therapies of JAK inhibitors and complementary agents that better address the complexity of the pathobiology of classic Ph-negative MPNs. Here, we discuss the role of tyrosine-kinase inhibitors in the current MPN-treatment landscape.
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Affiliation(s)
- Javier Pinilla-Ibarz
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kendra L Sweet
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gabriela M Corrales-Yepez
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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8
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Soverini S, De Benedittis C, Mancini M, Martinelli G. Best Practices in Chronic Myeloid Leukemia Monitoring and Management. Oncologist 2016; 21:626-33. [PMID: 27032870 DOI: 10.1634/theoncologist.2015-0337] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/21/2016] [Indexed: 12/24/2022] Open
Abstract
UNLABELLED : Optimal use of current therapeutic opportunities for chronic myeloid leukemia patients requires integration of clinical and laboratory monitoring. Assessment of molecular response (MR) by real-time quantitative polymerase chain reaction is the most sensitive way to monitor tyrosine kinase inhibitor (TKI) treatment efficacy. Besides major molecular response, which has emerged as a safe haven for survival since the initial studies of first-line imatinib treatment, two additional MR milestones have recently been defined: early molecular response and deep molecular response. The achievement of such MR milestones within defined time points during therapy is thought to draw the ideal trajectory toward optimal long-term outcome and, possibly, successful treatment discontinuation. Sensitive and reproducible MR measurement and proper interpretation of MR results are therefore critical to correctly inform therapeutic decisions. In patients who do not achieve an optimal response to TKI therapy, BCR-ABL1 mutation screening should also be performed, because it may deliver useful information for TKI choice. This review aims to help clinicians apply and translate the latest response definitions and clinical recommendations into practice. We provide a critical update on how these recommendations have incorporated MR levels in the clinical decision algorithms and how detection of BCR-ABL1 mutations should be interpreted. We also include a practical guide for pathologists and molecular biologists to best perform molecular testing and for hematologists and oncologists to best integrate it into routine practice. IMPLICATIONS FOR PRACTICE Ever-more-potent therapeutic strategies have been developed for chronic myeloid leukemia (CML) in parallel with the evolution of therapeutic goals and the refinement of response definitions and monitoring schemes and procedures. Terminology and methodology continue to evolve rapidly, making it difficult for busy hematology/oncology professionals to keep abreast of the newest developments. Optimal CML patient management results from the timely and rational use of molecular testing, the critical assessment of the power and pitfalls of current technology, and the appropriate interpretation and contextualization of results.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Caterina De Benedittis
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
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Amare PSK, Jain H, Kabre S, Walke D, Menon H, Sengar M, Khatri N, Bagal B, Dangi U, Jain H, Subramanian PG, Gujral S. Characterization of Genomic Events Other than Ph and Evaluation of Prognostic Influence on Imatinib in Chronic Myeloid Leukemia (CML): A Study on 1449 Patients from India. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/jct.2016.74030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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Al-Dewik NI, Jewell AP, Yassin MA, Morsi HM. Studying the Impact of Presence of Alpha Acid Glycoprotein and Protein Glycoprotein in Chronic Myeloid Leukemia Patients Treated with Imatinib Mesylate in the State of Qatar. BIOMARKERS IN CANCER 2015; 7:63-7. [PMID: 26640393 PMCID: PMC4664201 DOI: 10.4137/bic.s31427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/14/2015] [Accepted: 10/17/2015] [Indexed: 01/26/2023]
Abstract
Despite the efficacy of imatinib mesylate (IM) in treating chronic myeloid leukemia (CML), there is a high degree of resistance. Alpha- 1-acid glycoprotein may reduce drug efficacy through its ability to interact with IM and blocks it from reaching its target, while protein glycoprotein (PGP) may reduce the intracellular concentration of the drug via an active pump mechanism. We thus investigated the correlation between AGP and PGP levels and the resistance/response to treatment. A total of 26 CML patients were investigated for AGP and PGP levels at diagnosis and during treatment. There was no significant difference or correlation between AGP levels and the different groups of patients. There was also no significant difference in the fluorescence intensities of PGP levels among the different patient groups. The resistance observed in our CML patient population could not be correlated with AGP and PGP levels. There was no significant pattern of AGP and PGP expression, irrespective of the response or resistance to treatment.
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Affiliation(s)
- Nader I Al-Dewik
- National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha, Qatar. ; Qatar Medical Genetics Center, Hamad Medical Corporation (HMC), Doha, Qatar. ; Faculty of Health and Social Care Sciences, Kingston University and St George's University of London, UK
| | - Andrew P Jewell
- Medical Research Centre, HMC, Doha, Qatar. ; Department of Hematology, University College of London (UCL), UK
| | - Mohammed A Yassin
- National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hisham M Morsi
- Faculty of Health and Social Care Sciences, Kingston University and St George's University of London, UK. ; Academic Health System (AHS), Hamad Medical Corporation (HMC), Doha, Qatar
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Pagnano KBB, Bendit I, Boquimpani C, De Souza CA, Miranda ECM, Zalcberg I, Larripa I, Nardinelli L, Silveira RA, Fogliatto L, Spector N, Funke V, Pasquini R, Hungria V, Chiattone CS, Clementino N, Conchon M, Moiraghi EB, Lopez JL, Pavlovsky C, Pavlovsky MA, Cervera EE, Meillon LA, Simões B, Hamerschlak N, Bozzano AHM, Mayta E, Cortes J, Bengió RM. BCR-ABL mutations in chronic myeloid leukemia treated with tyrosine kinase inhibitors and impact on survival. Cancer Invest 2015; 33:451-8. [PMID: 26288116 DOI: 10.3109/07357907.2015.1065499] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This is the largest Latin American study of BCR-ABL mutations in chronic myeloid leukemia (CML) patients, resistant to imatinib (IM). In 195/467 (41%) patients, mutations were detected. The most frequent mutation was T315I (n = 31, 16%). Progression-free (PFS) and overall survival (OS) at 5 years were lower in patients with BCR-ABL mutations (43% vs. 65%, p = 0.07 and 47% vs. 72%, p = 0.03, respectively) and in those with the T315I mutation (p = 0.003 and p = 0.03). OS and PFS were superior in subgroup who switched to second generation inhibitors (SGIs) after IM failure (OS: 50% vs. 39% p = 0.01; PFS: 48% vs. 30% p = 0.02). BCR-ABL mutations conferred a significant poor prognosis in CML patients.
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Affiliation(s)
| | - Israel Bendit
- b 2 Laboratório de Biologia Tumoral , University of São Paulo, São Paulo , São Paulo, Brazil
| | | | | | - Eliana C M Miranda
- a 1 Hemocentro-UNICAMP , University of Campinas, Campinas , São Paulo, Brazil
| | - Ilana Zalcberg
- d 4 Instituto Nacional do Câncer, Rio de Janeiro , Rio de Janeiro, Brazil
| | - Irene Larripa
- e 5 Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires , Buenos Aires, Argentina
| | - Luciana Nardinelli
- b 2 Laboratório de Biologia Tumoral , University of São Paulo, São Paulo , São Paulo, Brazil
| | | | - Laura Fogliatto
- f 6 Hospital das Clínicas de Porto Alegre, Porto Alegre , Rio Grande do Sul, Brazil
| | - Nelson Spector
- g 7 Federal University of Rio de Janeiro , Rio de Janeiro , Rio de Janeiro, Brazil
| | - Vaneuza Funke
- h 8 Universidade Federal do Paraná , Curitiba, Paraná, Brazil
| | | | - Vania Hungria
- i 9 Santa Casa de São Paulo, São Paulo , São Paulo, Brazil
| | | | - Nelma Clementino
- j 10 Universidade Federal de Minas Gerais , Belo Horizonte , Minas Gerais, Brazil
| | - Monika Conchon
- k 11 Hospital Santa Marcelina , São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | - Belinda Simões
- q 17 University of São Paulo , Ribeirão Preto, São Paulo, Brazil
| | | | | | | | - Jorge Cortes
- u 21 MD Anderson Cancer Center , Houston, Texas, USA
| | - Raquel M Bengió
- e 5 Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires , Buenos Aires, Argentina
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Park SH, Park CJ, Kim DY, Lee BR, Kim YJ, Cho YU, Jang S. MRP1 and P-glycoprotein expression assays would be useful in the additional detection of treatment non-responders in CML patients without ABL1 mutation. Leuk Res 2015; 39:1109-16. [PMID: 26248945 DOI: 10.1016/j.leukres.2015.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 11/25/2022]
Abstract
We evaluated the ability of the rhodamine-123 efflux assay, multidrug resistance-associated protein-1 (MRP1) expression assay and P-glycoprotein (Pgp) expression assay to discriminate chronic myelogenous leukemia (CML) patients who had failed treatment or were at risk of failure. Each assay was performed in blood samples from CML patients (n=224) treated with tyrosine kinase inhibitors, taken at diagnosis (n=14) and follow-up (n=210). Patient samples were categorized as optimal response (n=120), suboptimal response (n=54), and treatment failure (n=36). Treatment-failed patients had a significantly higher MRP1 expression (5.24% vs. 3.54%, P=0.006) and Pgp expression (5.25% vs. 3.48%, P=0.005) than responders. Both MRP1 (%) and Pgp (%) were highly specific (95.2% and 94.5%) and relatively accurate (83.0% and 82.5%) in the detection of treatment non-responders. Of treatment-failed patients, 41.2% had a positive result in at least one assay and of these patients without ABL1 kinase domain mutation, 51.9% were positive in at least one assay. However, the rhodamine-123 efflux assay failed to discriminate two patient groups. Thus, both MRP1 and Pgp expression assays could be useful for additional identification of treatment non-responders in CML patients without ABL1 mutation.
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Affiliation(s)
- Sang Hyuk Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea; Department of Laboratory Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.
| | - Dae-Young Kim
- Department of Hematology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.
| | - Bo-Ra Lee
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Young Jin Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
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Chi J, Pierides C, Mitsidou A, Miltiadou A, Gerasimou P, Costeas P. cDNA synthesis for BCR-ABL1 detection at the MMR level: the importance of using the appropriate kit. Biol Proced Online 2015; 17:4. [PMID: 25667568 PMCID: PMC4321704 DOI: 10.1186/s12575-015-0014-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background The synthesis of complementary DNA (cDNA) for use in the detection of BCR-ABL1 at the Major Molecular Response (MMR) level is a well-established method used by clinical laboratories world-wide. However, the quality of cDNA provides sensitivity challenges and consequently affects the detection of Minimal Residual Disease (MRD). Results Herein, we evaluated six commercially available kits for the synthesis of cDNA according to amplification success rate, linearity and ABL1 copy number. Based on our results, the Invitrogen SuperScript® III Reverse Transcriptase kit performed better, among the ones used in this study, for the cDNA synthesis, followed by the First Strand cDNA Synthesis Kit for RT-PCR (AMV), available from Roche Applied Sciences. Conclusions Accurate and sensitive testing for the detection of abnormal transcripts, allows the correct stratification and treatment of patients. Hence, the use of a suitable kit for the cDNA synthesis is of great importance. This study provides a comprehensive point of reference for clinical laboratories in an attempt to optimize BCR-ABL1 detection. We propose that the Invitrogen SuperScript® III Reverse Transcriptase kit is the most suitable, among the ones used in this study, for the cDNA synthesis to be used for the detection of BCR-ABL1 at the MMR level in a CML MRD assay. Electronic supplementary material The online version of this article (doi:10.1186/s12575-015-0014-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianxiang Chi
- The Center for the Study of Haematological Malignancies, Nicosia, Cyprus
| | - Chryso Pierides
- The Center for the Study of Haematological Malignancies, Nicosia, Cyprus
| | - Andrie Mitsidou
- The Center for the Study of Haematological Malignancies, Nicosia, Cyprus
| | | | | | - Paul Costeas
- The Center for the Study of Haematological Malignancies, Nicosia, Cyprus.,Karaiskakio Foundation, Nicosia, Cyprus
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14
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Bauer S, Romvari E. Interpreting molecular monitoring results and international standardization in chronic myeloid leukemia. J Adv Pract Oncol 2014; 3:151-60. [PMID: 25031941 PMCID: PMC4093320 DOI: 10.6004/jadpro.2012.3.3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Important advances in the understanding of the molecular basis of chronic myeloid leukemia have resulted in the development of new therapies and changed the paradigm for managing this myeloproliferative disease. Translocation of chromosomes 9 and 22 (known as the Philadelphia chromosome) results in a fusion BCR-ABL gene that produces a dysregulated BCR-ABL tyrosine kinase protein and triggers events leading to malignant transformation. The tyrosine kinase inhibitors imatinib, nilotinib, and dasatinib block the BCR-ABL protein and prevent activation of the transformation pathways. Molecular monitoring, the most sensitive approach currently available to assess treatment response, measures BCR-ABL messenger RNA levels and serves as a surrogate marker of disease. Further, molecular responses are predictive of patient outcomes. It is important for advanced practitioners to become familiar with the technology and interpretation of molecular monitoring results as well as efforts to standardize this type of testing so they can educate their patients and aid their understanding of test results. Undetectable BCR-ABL levels can bring feelings of relief, whereas an increasing level can lead to anxiety. Advanced practitioners, therefore, are an important resource for interpreting results for patients, answering questions, alleviating concerns, and encouraging continued adherence to treatment.
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Affiliation(s)
- Stephanie Bauer
- Bone Marrow Transplant Division in the School of Medicine, Washington University, St. Louis, Missouri
| | - Edie Romvari
- Bone Marrow Transplant Division in the School of Medicine, Washington University, St. Louis, Missouri
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15
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Menon H. Issues in current management of chronic myeloid leukemia: Importance of molecular monitoring on long term outcome. South Asian J Cancer 2014; 2:38-43. [PMID: 24455544 PMCID: PMC3876638 DOI: 10.4103/2278-330x.105893] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Monitoring of CML patients while on therapy is vitally important and ENL has come up with specific guidelines for the same. Since we are currently talking about operational cure, this review shall focus on evaluating the emerging data to optimize response. This requires attention to all outstanding controversial issues. Only careful, accurate and regular monitoring with specific attention to grey areas will help us select first line therapy, decide when to discontinue TKIs and also move to second line TKIs in a timely manner.
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Affiliation(s)
- Hari Menon
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
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16
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Simalatsar A, You W, Gotta V, Widmer N, De Micheli G. Representation of Medical Guidelines with a Computer Interpretable Model. INT J ARTIF INTELL T 2014. [DOI: 10.1142/s0218213014600033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nowadays medical software is tightly coupled with medical devices that perform patient state monitoring and lately even some basic treatment procedures. Medical guidelines (GLs) can be seen as specification of a medical system which requires their computer-interpretable representation of medical GLs. Until now most of the medical GLs are often represented in a textual format and therefore often suffer from such structural problems as incompleteness, inconsistencies, ambiguity and redundancy, which makes the translation process to the machine-interpretable language more complicated. Computer-based interpretation of GLs can improve the quality of protocols as well as the quality of medical service. Several GLs formal representation methods have been presented recently. Only some of them enable automatic formal verification by introducing an additional translation path to the existing model checking environments. However, if a verified property fails it is difficult to trace back the result needed to change the model. Moreover, these formalisms provide the notion of time mostly in terms of actions order. In this paper we preset the application of a well-know formal behaviour representation approach of embedded systems design domain to medical GLs interpretation. We use Timed Automata extended with Tasks (TAT) and TIMES toolbox to represent medical GLs as a system behaviour in a computer interpretable form. We discuss the verification issues with the help of the anticancer drug imatinib case study.
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Affiliation(s)
| | - Wenqi You
- École Polytechnique Fédérale de Lausanne, Switzerland
| | - Verena Gotta
- Division of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Lausanne and Geneva, Switzerland
| | - Nicolas Widmer
- Division of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
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17
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Kagita S, Uppalapati S, Jiwatani S, Linga VG, Gundeti S, Nagesh N, Digumarti R. Incidence of Bcr-Abl kinase domain mutations in imatinib refractory chronic myeloid leukemia patients from South India. Tumour Biol 2014; 35:7187-93. [PMID: 24763825 DOI: 10.1007/s13277-014-1926-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022] Open
Abstract
Mutations in the Bcr-Abl kinase domain (KD) are a major cause for acquired resistance to imatinib (IM) treatment and have been associated with progression and poor prognosis in chronic myeloid leukemia patients. The present study includes 63 patients resistant to standard imatinib dose of 400 mg according to ELN guidelines. Direct sequencing method is used for mutational analysis. The present study revealed 15 exonic mutations in 46.03 % of patients; among them, seven cases (24.13 %) had multiple mutations. Mutations were found to be higher in sokal high- (45.0 %) and intermediate- (68.42 %) compared to low-risk (29.16 %) group. Mutations were observed in 38.09 % of patients with EUTOS (European Treatment and Outcome Study) high risk and in 50.0 % with low risk. The frequency of mutations was 50.0 % in advanced phase, 47.36 % in late chronic-phase, and 43.33 % in chronic-phase patients. 42.10 % of patients with primary resistance and 52.0 % with secondary resistance had mutations. P-loop and T315I mutations were associated with poor survival in advanced phase patients (85.71 %) (P = 0.03). No significant variation was observed with Bcr-Abl transcript levels between the patients with the presence or absence of mutations (P = 0.73). Bcr-Abl levels were found to be significantly elevated in P-loop and T315I mutation carriers (P = 0.001) and also in T315I mutation-positive patients (P = 0.01). P-loop mutations and T315I are frequent in advanced phases and strongly associated with poor prognosis and survival. Hence, the identification of mutations in IM-resistant CML patients will help in treatment optimization with 2nd- or 3rd-generation tyrosine kinase inhibitors (TKIs).
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Affiliation(s)
- Sailaja Kagita
- Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, Andhra Pradesh, 500082, India
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Saleh MN, Haislip S, Sharpe J, Hess T, Gilmore J, Jackson J, Sail KR, Ericson SG, Chen L. Assessment of treatment and monitoring patterns and subsequent outcomes among patients with chronic myeloid leukemia treated with imatinib in a community setting. Curr Med Res Opin 2014; 30:529-36. [PMID: 24156689 DOI: 10.1185/03007995.2013.858621] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Real-world treatment and monitoring patterns have not been well documented among imatinib-treated chronic phase chronic myeloid leukemia (CP-CML) patients. Thus, we evaluated these patterns and responses to imatinib in CP-CML patients. METHODS This retrospective study, based on the Georgia Cancer Specialists' electronic medical record (EMR) system, identified CP-CML patients initiating treatment with imatinib from 01/01/2002 to 11/01/2011 who were subsequently followed for ≥6 months. RESULTS A total of 177 patients met the study criteria. Imatinib dose modification occurred in 59 patients (33%). Rates of treatment interruption, discontinuation, and switching to another therapy were 16%, 24%, and 23%, respectively. Of 27 patients discontinuing imatinib for lack of efficacy, 9 (33%) had initial dose escalation; 26 patients (96%) eventually switched to a second-generation tyrosine kinase inhibitor. By 3 months, 168 patients remained on imatinib, of whom 96 (57%) had undergone cytogenetic and/or molecular testing. The frequency of response monitoring fluctuated over time, with rates as high as 28% for cytogenetic and 69% for molecular testing. Cumulative response rates steadily increased; 18 month rates were 47% for complete cytogenetic response and 26% for major or complete molecular response. There were no cases of progression and/or death among 38 patients who were regularly monitored for molecular response within the first 12 months of imatinib. Ten of 98 patients (10%) not regularly monitored had progressed or died. CONCLUSIONS Almost one-third of patients initiating imatinib for CP-CML required dose modification, treatment interruption, or discontinuation. Opportunities for improved monitoring in this setting were identified. Limitations include those inherent to retrospective analyses based on EMR and the uncertain extrapolability of the results.
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19
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Vine J, Cohen SB, Ruchlemer R, Goldschmidt N, Levin M, Libster D, Gural A, Gatt ME, Lavie D, Ben-Yehuda D, Rund D. Polymorphisms in the human organic cation transporter and the multidrug resistance gene: correlation with imatinib levels and clinical course in patients with chronic myeloid leukemia. Leuk Lymphoma 2014; 55:2525-31. [DOI: 10.3109/10428194.2014.893307] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jacob Vine
- Department of Medicine, Hebrew University-Hadassah Medical School,
Jerusalem, Israel
| | - Sara Bar Cohen
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Rosa Ruchlemer
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Neta Goldschmidt
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Moshe Levin
- Department of Hematology Mt. Scopus, Shaare Zedek Medical Center,
Jerusalem, Israel
| | - Diana Libster
- Department of Hematology Mt. Scopus, Shaare Zedek Medical Center,
Jerusalem, Israel
| | - Alexander Gural
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Moshe E. Gatt
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - David Lavie
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Dina Ben-Yehuda
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
| | - Deborah Rund
- Department of Hematology, Hebrew University-Hadassah Medical Organization,
Jerusalem, Israel
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20
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Gonzalez M, De Brasi C, Ferri C, Bengió R, Bianchini M, Larripa I. CAMKIIγ, HSP70 and HSP90 transcripts are differentially expressed in chronic myeloid leukemia cells from patients with resistant mutated disease. Leuk Lymphoma 2014; 55:2101-8. [PMID: 24206096 DOI: 10.3109/10428194.2013.861070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients with chronic myeloid leukemia (CML) can develop disease resistance to tyrosine kinase inhibitor (TKI) therapy, which is mainly attributable to the presence of point mutations in the tyrosine kinase domain of BCR-ABL1. In order to examine suitable markers to monitor treatment efficacy, we investigated transcript expression profiles of genes known to be involved in myeloid cell proliferation, such as CAMKIIγ and KI67, and in protein stability and ultimately cell survival under physiological and stress conditions, such as heat shock proteins HSP70 and HSP90. We studied 101 patients with CML in different stages of disease and with different responses to TKI treatment. The results of quantitative real-time polymerase chain reaction (qPCR) analyses showed that the expression levels of CAMKIIγ, KI67, HSP70 and HSP90 genes were up-regulated at diagnosis, and in cases with signs of treatment resistance both in chronic and advanced phases (accelerated and blastic phases) with respect to chronic phase in remission and healthy donors. When only 56 resistant cases, 31 with mutations (MT) and 25 without mutations (WT), in the BCR-ABL1 tyrosine kinase domain were considered, the transcript expression profile showed an unexpected significant increase in CAMKIIγ and HSP70, and a significant decrease in HSP90 in MT versus WT cases. This differential transcript expression prompted us to design an expression score, log(CAMKIIγ × HSP70/HSP90), which can be used to provide rapid screening to discriminate the presence or absence of mutations in resistant cells and to monitor TKI treatment efficacy in patients with CML.
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21
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Loberiza FR, Cannon AC, Cannon AJ, Bierman PJ. Insights on practice variations in the management of lymphoma and leukemia. Leuk Lymphoma 2014; 55:2449-56. [DOI: 10.3109/10428194.2014.881480] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Fausto R. Loberiza
- Section of Oncology/Hematology, Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Andrew C. Cannon
- Section of Oncology/Hematology, Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Anthony J. Cannon
- Section of Oncology/Hematology, Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Philip J. Bierman
- Section of Oncology/Hematology, Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
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22
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Di Paolo A, Polillo M, Capecchi M, Cervetti G, Baratè C, Angelini S, Guerrini F, Fontanelli G, Arici R, Ciabatti E, Grassi S, Bocci G, Hrelia P, Danesi R, Petrini M, Galimberti S. The c.480C>G polymorphism of hOCT1 influences imatinib clearance in patients affected by chronic myeloid leukemia. THE PHARMACOGENOMICS JOURNAL 2014; 14:328-35. [PMID: 24589908 DOI: 10.1038/tpj.2014.7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 01/17/2014] [Accepted: 01/31/2014] [Indexed: 12/30/2022]
Abstract
The aim of the study was to investigate any possible influence of polymorphisms of transmembrane transporters human organic cation transporter 1 (hOCT1), ABCB1, ABCG2 on imatinib pharmacokinetics in 33 men and 27 women (median age and range, 56 and 27-79 years, respectively) affected by chronic myeloid leukemia. A population pharmacokinetic analysis was performed to investigate imatinib disposition in every patient and the role of transporter polymorphisms. Results showed that the α1-acid glycoprotein and the c.480C>G genotype of hOCT1 had a significant effect on apparent drug clearance (CL/F) being responsible, respectively, for a 20% and 10% decrease in interindividual variability (IIV) of CL/F (from 50.1 up to 19.6%). Interestingly, 25 patients carrying at least one polymorphic c.480 G allele had a significant lower CL/F value with respect to the 35 c.480CC individuals (mean±s.d., 9.6±1.6 vs 12.1±2.3 l h(-1), respectively; P<0.001). In conclusion, the hOCT1 c.480C>G SNP may significantly influence imatinib pharmacokinetics, supporting further analyses in larger groups of patients.
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Affiliation(s)
- A Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - M Polillo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - M Capecchi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - G Cervetti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - C Baratè
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - S Angelini
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 48, Bologna, Italy
| | - F Guerrini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - G Fontanelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - R Arici
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - E Ciabatti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - S Grassi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - G Bocci
- 1] Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy [2] Istituto Toscano Tumori, Via Alderotti 86/N, Florence, Italy
| | - P Hrelia
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 48, Bologna, Italy
| | - R Danesi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - M Petrini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
| | - S Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, Pisa, Italy
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Abstract
The treatment of chronic myeloid leukemia (CML) has been revolutionized by the small molecule selective kinase inhibitor imatinib mesylate. Imanitib was the first BCR-ABL targeted agent approved for the treatment of CML patients and confers significant response in most patients; however, a substantial number of patients are initially refractory to the drug or may develop resistance during the course of treatment. Point mutations in the kinase domain (KD) of BCR-ABL that impact drug binding have been identified as one of the major mechanisms of resistance. We present here an overview of the current practice in monitoring for such mutations, including the methods used, criteria for investigating and guidelines for reporting the mutations. We further present and discuss the experience of our own laboratory in studying the KD mutations in Indian CML patients on imatinib treatment.
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Affiliation(s)
- Shweta Srivastava
- Department of Molecular Pathology, OncQuest Laboratories Ltd., New Delhi, India
| | - Sarjana Dutt
- Department of Molecular Pathology, OncQuest Laboratories Ltd., New Delhi, India
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24
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Elghannam DM, Ibrahim L, Ebrahim MA, Azmy E, Hakem H. Association of MDR1 gene polymorphism (G2677T) with imatinib response in Egyptian chronic myeloid leukemia patients. ACTA ACUST UNITED AC 2013; 19:123-8. [PMID: 23683876 DOI: 10.1179/1607845413y.0000000102] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Despite the excellent efficacy results of imatinib treatment in CML patients, resistance to imatinib has emerged as a significant problem. Genetic variations in genes involved in drug transportation might influence the pharmacokinetic and metabolism of imatinib. The genotype of a patient is increasingly recognized in influencing the response to the treatment. AIM To investigate the genotype frequencies of single nucleotide polymorphisms (SNPs) G2677T in CML patients undergoing imatinib treatment to determine whether different genotype pattern of these SNPs have any influence in mediating response to imatinib. METHODS A total of 96 CML and 90 control samples were analyzed for the human multidrug resistance gene 1 (MDR1) gene polymorphism (G2677T) using polymerase chain reaction-restriction fragment length polymorphism technique. RESULTS Genotype distribution revealed a significant lower frequency of TT genotype in CML patients and non-significant difference in the GG, GT genotype frequencies between patients and controls (P = 0.004, 0.138, 0.210, respectively). GG genotype was significantly higher in chronic phase (P = 0.046), while GT genotype was significantly higher in Blastic crisis phase (P = 0.002). There was a significant difference in genotype frequency of G2677T among patients showing response and resistance to imatinib in chronic phase (P = 0.02). TT genotype was associated with complete hematological response (P = 0.01), complete cytogenetic response (P < 0.001), and better molecular response with a significant association (P < 0.001). GT genotype was associated with partial hematological response (P = 0.01) and minor cytogenetic response (P < 0.001). Optimal and suboptimal responses were observed for patients with TT genotype (P = 0.003). Failure of drug response was associated with GT genotype (P = 0.02); however, GG had no association with drug response. Multivariate analysis considered GT genotype as independent risk factor for resistance (P = 0.037), while TT genotype as protective factor against resistance to imatinib (P = 0.008). CONCLUSION Determination of MDR1 polymorphisms (G2677T) might be useful in response prediction to therapy with imatinib in patients with CML.
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Simalatsar A, De Micheli G. TAT-based formal representation of medical guidelines: imatinib case-study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:5078-81. [PMID: 23367070 DOI: 10.1109/embc.2012.6347135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Computer-based interpretation of medical guidelines (GLs) has drawn lots of attention in the past three decades. It is essential to use a formalism for GLs representation that would enable the validation of GLs structural properties, be able to map medical actions into the time scale and support the automatic formal verification of GLs without additional translation paths. In this paper we preset a novel approach based on Timed Automata extended with Tasks (TAT) for the medical protocol formal representation using the TIMES toolbox. We discuss the verification issues with the help of the Imatinib case study.
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Affiliation(s)
- Alena Simalatsar
- Integrated Systems Laboratory, EPFL, 1015 Lausanne, Switzerland.
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26
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Zhen C, Wang YL. Molecular monitoring of chronic myeloid leukemia: international standardization of BCR-ABL1 quantitation. J Mol Diagn 2013; 15:556-64. [PMID: 23876601 DOI: 10.1016/j.jmoldx.2013.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/24/2013] [Accepted: 05/15/2013] [Indexed: 11/17/2022] Open
Abstract
The BCR-ABL1 translocation is a hallmark of chronic myeloid leukemia. Because patients treated with imatinib and other tyrosine kinase inhibitors achieve lower levels of detectable disease, quantitation of BCR-ABL1 transcripts with quantitative RT-PCR has become an essential tool in chronic myeloid leukemia monitoring. The prognostic significance of molecular responses was recently established by large-scale clinical trials. Achieving defined levels of BCR-ABL1 on the International Scale within specific time frames is an important measure for assessing patient response and probability for relapse and progression. However, extensive variation in quantitative RT-PCR procedures and reporting makes it difficult to interpret these results. More important, lack of standardization, particularly in the United States, prevents the comparison of individual patient results to the data from the clinical trials, which thereby prohibits the meaningful use of such results in the direction of patient care. In this article, we will present an overview of the clinical trial discoveries that drive the need for standardization, review the most updated monitoring guidelines by the National Comprehensive Cancer Network, and highlight recommendations for laboratory practice regarding internal controls and reference materials. Finally, we will provide an update on the recent efforts in the standardization of quantitative RT-PCR reporting using the International Scale.
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MESH Headings
- Fusion Proteins, bcr-abl/genetics
- Genetic Testing/methods
- Genetic Testing/standards
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Practice Guidelines as Topic
- Prognosis
- Reference Standards
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Affiliation(s)
- ChaoJie Zhen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York, USA
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27
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Sweet K, Zhang L, Pinilla-Ibarz J. Biomarkers for determining the prognosis in chronic myelogenous leukemia. J Hematol Oncol 2013; 6:54. [PMID: 23870290 PMCID: PMC3737033 DOI: 10.1186/1756-8722-6-54] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 06/19/2013] [Indexed: 11/25/2022] Open
Abstract
The introduction of BCR-ABL1 tyrosine kinase inhibitors (TKIs) for treatment of chronic myelogenous leukemia in chronic phase (CML-CP) has revolutionized therapy, altering the outcome from one of shortened life expectancy to long-term survival. With over 10 years of long-term treatment with imatinib and several years of experience with the next generation of TKIs, including nilotinib, dasatinib, bosutinib, and ponatinib, it is becoming clear that many clinical parameters have great impact on the prognosis of patients with CML. Emerging novel gene expression profiling and molecular techniques also provide new insights into CML pathogenesis and have identified potential prognostic markers and therapeutic targets. This review presents the supporting data and discusses how certain clinical characteristics at diagnosis, the depth of early response, the presence of certain kinase domain mutations, and additional molecular changes serve as prognostic factors that may guide individualized treatment decisions for patients with CML-CP.
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28
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Chahardouli B, Zaker F, Mousavi SA, Kazemi A, Ostadali M, Nadali F, Rostami S, Alimoghaddam K, Ghavamzade A. Evaluation of T315I mutation frequency in chronic myeloid leukemia patients after imatinib resistance. ACTA ACUST UNITED AC 2013; 18:158-62. [PMID: 23540562 DOI: 10.1179/1607845412y.0000000050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The occurrence of resistance mutations in the Abl kinase domain plays a central role in drug treatment failure in chronic myeloid leukemia (CML) patients. Among them, the T315I mutation at the gatekeeper position affects a common Abl kinase contact residue and confers complete resistance to all known ATP-competitive BCR-ABL inhibitors. In the present study, an allele-specific oligonucleotide reverse transcriptase polymerase chain reaction assay was used to detect T315I mutation in a cohort of 60 imatinib-resistant CML patients. In terms of disease phase, 43 patients (71%) were in late chronic phase, 4 (7%) in accelerated phase, and 13 (22%) in blastic phase. The prevalence of the T315I mutation was found to be 7% (4/60). All four patients with mutation were in advance phases and had previously lost all their responses. The results of the study confirmed that this method is low cost and easy tool to operate for T315I mutation screening and direct sequencing should be performed in positive cases for confirmation.
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Affiliation(s)
- Bahram Chahardouli
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Shariati Hospital, Kargar Avenue, Tehran, Iran
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La Nasa G, Caocci G, Littera R, Atzeni S, Vacca A, Mulas O, Langiu M, Greco M, Orrù S, Orrù N, Floris A, Carcassi C. Homozygosity for killer immunoglobin-like receptor haplotype A predicts complete molecular response to treatment with tyrosine kinase inhibitors in chronic myeloid leukemia patients. Exp Hematol 2013; 41:424-31. [PMID: 23380384 DOI: 10.1016/j.exphem.2013.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 01/28/2013] [Accepted: 01/31/2013] [Indexed: 11/29/2022]
Abstract
Several recent reports suggest a possible role for killer immunoglobulin-like receptors (KIR) in the onset of chronic myeloid leukemia (CML) and response to therapy with tyrosine kinase inhibitors (TKIs). To explore this hypothesis, we studied KIRs and their human leukocyte antigen class I ligands in 59 consecutive patients with chronic-phase CML (mean age, 53 years; range, 23-81 years) and a group of 121 healthy control participants belonging to the same ethnic group as the patients. The 2-year cumulative incidence of complete molecular response, obtained after a median of 27 months (range, 4-52 months), was 51.2%. An increased frequency of the activating receptor KIR2DS1 (pm = 0.05) and a reduced frequency of the KIR-ligand combination KIR2DS2/2DL2 absent/C1 present (pm = 0.001) were significantly associated with CML. Moreover, KIR repertoires in patients appeared to influence response to TKI therapy. Homozygosity for KIR haplotype A (pm = 0.01), a decreased frequency of the inhibitory KIR gene KIR2DL2 (pm = 0.02), and low numbers of inhibitory KIR genes (pm = 0.05) were all significantly associated with achievement of complete molecular remission. These data suggest that a decrease in properly stimulated and activated NK cells might contribute to the occurrence of CML and indicate homozygosity for KIR haplotype A as a promising immunogenetic marker of complete molecular response that could help clinicians decide whether to withdraw treatment in patients with CML.
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Affiliation(s)
- Giorgio La Nasa
- Bone Marrow Transplant Center, R. Binaghi Hospital - ASL 8, Cagliari, Italy.
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GROMICHO MARTA, MAGALHÃES MARTA, TORRES FÁTIMA, DINIS JOANA, FERNANDES ALEXANDRAR, RENDEIRO PAULA, TAVARES PURIFICAÇÃO, LAIRES ANTÓNIO, RUEFF JOSÉ, RODRIGUES ANTÓNIOSEBASTIÃO. Instability of mRNA expression signatures of drug transporters in chronic myeloid leukemia patients resistant to imatinib. Oncol Rep 2012; 29:741-50. [DOI: 10.3892/or.2012.2153] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 09/07/2012] [Indexed: 11/05/2022] Open
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31
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Vigil CE, Griffiths EA, Wang ES, Wetzler M. Improving the Quality of Quantitative Real-Time Polymerase Chain Reaction Laboratory Reporting in Chronic Myeloid Leukemia. Lab Med 2012. [DOI: 10.1309/lmse7m60tabhdnev] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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32
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Bouchet S, Titier K, Moore N, Lassalle R, Ambrosino B, Poulette S, Schuld P, Belanger C, Mahon FX, Molimard M. Therapeutic drug monitoring of imatinib in chronic myeloid leukemia: experience from 1216 patients at a centralized laboratory. Fundam Clin Pharmacol 2012; 27:690-7. [PMID: 23113675 DOI: 10.1111/fcp.12007] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/04/2012] [Accepted: 09/17/2012] [Indexed: 11/28/2022]
Abstract
This study set out to examine in a large real-life cohort of patients with chronic myeloid leukemia (CML) the impact of imatinib threshold of 1000 ng/mL on molecular response, as suggested in a small subset of patients. Patient plasma samples were submitted from around France to a central facility, free of charge under the auspices of the European Treatment and Outcome Study (EUTOS) for CML. Submitting physicians were required to complete an 'imatinib monitoring request form', including details of why therapeutic drug monitoring (TDM) was requested, dose and duration of imatinib treatment, cytogenetic and molecular response, adverse events, and concurrent medications. Imatinib trough plasma concentration (C(min)) was measured at the central facility. Among 1985 eligible plasma samples analyzed, from 1216 CML patients, imatinib C(min) correlated positively with reported imatinib dose, but interpatient variability in C(min) was high (60%). A logistic regression analysis revealed that treatment duration and imatinib C(min) > 1000 ng/mL were significantly associated with major and complete molecular responses with odds ratios of 1.69 and 2.08, respectively. These data support in real-life setting that imatinib C(min) threshold of 1000 ng/mL is associated with major and complete molecular response and that TDM could play an important role in dose optimization.
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Affiliation(s)
- Stéphane Bouchet
- Univ Bordeaux, F-33000, Bordeaux, France; INSERM U657, F-33000, Bordeaux, France; CHU Bordeaux, F-33000, Bordeaux, France
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33
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Jabbour EJ, Quintás-Cardama A. Molecular monitoring 101: helping your patients with chronic myeloid leukemia to understand the meaning of molecular response. Leuk Lymphoma 2012; 53:1452-60. [PMID: 22273251 DOI: 10.3109/10428194.2012.659734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
For patients with chronic myeloid leukemia (CML), measurement of molecular response (i.e. the level of BCR-ABL1 transcripts) is firmly established as a key element of disease monitoring. Assessment of BCR-ABL1 levels may help to identify early signs of resistance to treatment and enable a timely switch to alternative therapies. Hence, regular and accurate monitoring of BCR-ABL1 transcripts helps to maximize the chance of successful outcomes in CML. Because the incidence of CML is relatively low, many community oncologists encounter only a limited number of cases; measuring and interpreting BCR-ABL1 measurements in a clinically relevant fashion may be challenging. The team at our institution often encounters questions regarding real-time quantitative polymerase chain reaction assessments of BCR-ABL1 levels, International Scale standardization, the implications of achieving or losing molecular responses and mutation monitoring. The aim of this article is to provide practical advice for effective long-term monitoring of patients with CML by addressing frequently asked questions and common case scenarios using guideline- and evidence-based approaches.
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Affiliation(s)
- Elias J Jabbour
- Department of Leukemia, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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O'Hare T, Zabriskie MS, Eiring AM, Deininger MW. Pushing the limits of targeted therapy in chronic myeloid leukaemia. Nat Rev Cancer 2012; 12:513-26. [PMID: 22825216 DOI: 10.1038/nrc3317] [Citation(s) in RCA: 233] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Tyrosine kinase inhibitor (TKI) therapy targeting the BCR-ABL1 kinase is effective against chronic myeloid leukaemia (CML), but is not curative for most patients. Minimal residual disease (MRD) is thought to reside in TKI-insensitive leukaemia stem cells (LSCs) that are not fully addicted to BCR-ABL1. Recent conceptual advances in both CML biology and therapeutic intervention have increased the potential for the elimination of CML cells, including LSCs, through simultaneous inhibition of BCR-ABL1 and other newly identified, crucial targets.
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Affiliation(s)
- Thomas O'Hare
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Salt Lake City, Utah 84112, USA.
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Bixby DL. Managing inadequate responses to frontline treatment of chronic myeloid leukemia: a case-based review. Cancer Treat Rev 2012; 39:241-51. [PMID: 22818213 DOI: 10.1016/j.ctrv.2012.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 04/24/2012] [Accepted: 04/26/2012] [Indexed: 12/31/2022]
Abstract
The tyrosine kinase inhibitors (TKIs) imatinib, nilotinib, and dasatinib are the standard of care for treating patients with newly diagnosed chronic-phase chronic myeloid leukemia (CML). Compared with interferon-based treatment, the previous standard of care, imatinib is associated with significantly higher cytogenetic response rates and prolonged overall survival. Nilotinib and dasatinib, both newer and more potent TKIs, significantly improve cytogenetic and molecular response rates compared with imatinib. Despite significant advances in CML treatment enabled by the TKIs, a fraction of patients who receive frontline treatment with a TKI demonstrate inadequate response. The reasons for this vary, but in many cases, inadequate response can be attributed to non-adherence to the treatment regimen, intolerance to the drug, intrinsic or acquired resistance to the drug, or a combination of reasons. More often than not, strategies to improve response necessitate a change in treatment plan, either a dose adjustment or a switch to an alternate drug, particularly in the case of drug intolerance or drug resistance. Improved physician-patient communication and patient education are effective strategies to address issues relating to adherence and intolerance. Because inadequate response to TKI treatment correlates with poor long-term outcomes, it is imperative that patients who experience intolerance or who fail to achieve appropriate responses are carefully evaluated so that appropriate treatment modifications can be made to maximize the likelihood of positive long-term outcome.
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Affiliation(s)
- Dale L Bixby
- Department of Internal Medicine, University of Michigan Comprehensive Cancer Center, 1500 East Medical Center Drive, Room 4214 CC, Ann Arbor, MI 48109, United States.
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36
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Karvela M, Helgason GV, Holyoake TL. Mechanisms and novel approaches in overriding tyrosine kinase inhibitor resistance in chronic myeloid leukemia. Expert Rev Anticancer Ther 2012; 12:381-92. [PMID: 22369329 DOI: 10.1586/era.12.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic myeloid leukemia is a stem cell-initiated but progenitor-driven disease induced by the BCR-ABL oncogene. Tyrosine kinase inhibitors (TKIs) were introduced in the late 1990s and have revolutionized the management of chronic myeloid leukemia in chronic phase. The majority of patients can now expect to live a normal life as long as they continue to comply with TKI treatment. However, in a significant proportion of cases TKI resistance develops over time, requiring a switch of therapy. The most frequent mechanism for drug resistance is the development of kinase domain mutations that reduce or completely ablate drug efficacy. Fortunately, the last 10 years have seen an impressive array of new drugs, some modeled on the mechanism of action of imatinib, others employing more novel approaches, for these patients.
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Affiliation(s)
- Maria Karvela
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 OYN, UK
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37
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Abstract
Targeted small-molecule drugs have revolutionized treatment of chronic myeloid leukemia (CML) during the last decade. These agents interrupt a constitutively active BCR-ABL, the causative agent for CML, by interfering with adenosine 5' triphosphate-dependent ABL tyrosine kinase. Although the efficacy of tyrosine kinase inhibitors (TKIs) has resulted in overall survival of greater than 90%, TKIs are not curative. Moreover, no currently approved TKIs are effective against the T315I BCR-ABL variant. However, a new generation of TKIs with activity against T315I is on the horizon. We will highlight the clinical utility of historical CML therapeutics, those used today (first- and second-generation TKIs), and discuss treatment modalities that are under development. Recent advances have illuminated the complexity of CML, especially within the marrow microenvironment. We contend that the key to curing CML will involve strategies beyond targeting BCR-ABL because primitive human CML stem cells are not dependent on BCR-ABL. Ultimately, drug combinations or exploiting synthetic lethality may transform responses into definitive cures for CML.
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Tibes R, Mesa RA. Evolution of clinical trial endpoints in chronic myeloid leukemia: Efficacious therapies require sensitive monitoring techniques. Leuk Res 2012; 36:664-71. [DOI: 10.1016/j.leukres.2012.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 02/06/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
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39
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Jalkanen SE, Lahesmaa-Korpinen AM, Heckman CA, Rantanen V, Porkka K, Hautaniemi S, Mustjoki S. Phosphoprotein profiling predicts response to tyrosine kinase inhibitor therapy in chronic myeloid leukemia patients. Exp Hematol 2012; 40:705-714.e3. [PMID: 22659387 DOI: 10.1016/j.exphem.2012.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/16/2012] [Accepted: 05/22/2012] [Indexed: 10/28/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) have dramatically improved treatment outcomes in chronic myeloid leukemia (CML), but a proportion of patients fail to achieve optimal molecular response. By using a phosphoproteomic approach, we aimed to discover aberrant signaling pathways and putative biomarkers in bone marrow samples of suboptimally responding patients, which could be used to guide treatment selection at the diagnosis. The study consisted of 20 chronic-phase CML patients (10 optimal and 10 suboptimal response patients based on 18 months European-Leukemia-Net criteria) and healthy bone marrow cells, and CML cell lines were used as controls. The phosphorylation profile of normal bone marrow cells diverged from CML patients expectedly but, interestingly, CML cell lines (such as K562) also showed marked difference with primary CML cells. Several phosphoproteins were elevated in suboptimal patients compared to optimal response group. Most prominent differences were seen in signal transducers and activators of transcription 5b, phospholipase C γ-1, proline-rich tyrosine kinase 2, Hck, and Paxillin. These phosphoproteins were also increased in three additional nonresponder patients studied, but each of them also had unique phosphorylation patterns, such as highly active HSP27 protein in one patient. In conclusion, suboptimal imatinib response is related to increased phosphorylation of several proteins at diagnosis, which might guide the selection of TKI therapy. Furthermore, the activation of additional BCR-ABL-independent pathways in nonresponder patients (such as the anti-apoptotic HSP27 pathway) may reveal novel therapy targets.
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Affiliation(s)
- Sari E Jalkanen
- Hematology Research Unit Helsinki, Department of Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
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40
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Definitions, methodological and statistical issues for phase 3 clinical trials in chronic myeloid leukemia: a proposal by the European LeukemiaNet. Blood 2012; 119:5963-71. [PMID: 22508936 DOI: 10.1182/blood-2011-10-383711] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The treatment policy of chronic myeloid leukemia (CML), particularly with tyrosine kinase inhibitors, has been influenced by several recent studies that were well designed and rapidly performed, but their interpretation is of some concern because different end points and methodologies were used. To understand and compare the results of the previous and future studies and to translate their conclusion into clinical practice, there is a need for common definitions and methods for analyses of CML studies. A panel of experts was appointed by the European LeukemiaNet with the aim of developing a set of definitions and recommendations to be used in design, analyses, and reporting of phase 3 clinical trials in this disease. This paper summarizes the consensus of the panel on events and major end points of interest in CML. It also focuses on specific issues concerning the intention-to-treat principle and longitudinal data analyses in the context of long-term follow-up. The panel proposes that future clinical trials follow these recommendations.
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41
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Alikian M, Gerrard G, Subramanian PG, Mudge K, Foskett P, Khorashad JS, Lim AC, Marin D, Milojkovic D, Reid A, Rezvani K, Goldman J, Apperley J, Foroni L. BCR-ABL1 kinase domain mutations: methodology and clinical evaluation. Am J Hematol 2012; 87:298-304. [PMID: 22231203 DOI: 10.1002/ajh.22272] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 11/24/2011] [Accepted: 12/01/2011] [Indexed: 12/31/2022]
Abstract
The introduction of tyrosine kinase inhibitors (TKIs), starting with imatinib and followed by second and third generation TKIs, has significantly changed the clinical management of patients with chronic myeloid leukemia (CML). Despite their unprecedented clinical success, a proportion of patients fail to achieve complete cytogenetic remission by 12 months of treatment (primary resistance) while others experience progressive resistance after an initial response (secondary resistance). BCR-ABL1 kinase domain (KD) mutations have been detected in a proportion of patients at the time of treatment failure, and therefore their identification and monitoring plays an important role in therapeutic decisions particularly when switching TKIs. When monitoring KD mutations in a clinical laboratory, the choice of method should take into account turnaround time, cost, sensitivity, specificity, and ability to accurately quantify the size of the mutant clone. In this article, we describe in a "manual" style the methods most widely used in our laboratory to monitor KD mutations in patients with CML including direct sequencing, D-HPLC, and pyrosequencing. Advantages, disadvantages, interpretation of results, and their clinical applications are reviewed for each method.
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MESH Headings
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Chromatography, High Pressure Liquid/methods
- DNA Mutational Analysis/methods
- Drug Resistance, Neoplasm/genetics
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Genes, abl
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Mutation
- Polymerase Chain Reaction/methods
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Protein Structure, Tertiary/genetics
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Protein-Tyrosine Kinases/genetics
- Quality Control
- RNA, Messenger/genetics
- RNA, Messenger/isolation & purification
- RNA, Neoplasm/genetics
- RNA, Neoplasm/isolation & purification
- Sequence Analysis, DNA/methods
- Specimen Handling
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Affiliation(s)
- Mary Alikian
- Imperial Molecular Pathology Laboratory, Imperial College NHS Trust and Academic Science Centre, Hammersmith Hospital, London W12 OHS, United Kingdom
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Seiter K. Considerations in the Management of Elderly Patients With Chronic Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 12:12-9. [DOI: 10.1016/j.clml.2011.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 09/30/2011] [Accepted: 10/04/2011] [Indexed: 11/27/2022]
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Bacher U, Talano JA, Bishop MR. Monitoring and Prevention of Relapse after Allogeneic Hematopoietic Cell Transplantation for Myeloid Malignancies. Biol Blood Marrow Transplant 2012; 18:S62-73. [DOI: 10.1016/j.bbmt.2011.10.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disorder that affects 5000 new patients per year in the United States. Prior to 10 years ago, durable remission was rare and patients often underwent bone marrow transplantation with substantial morbidity and mortality. Fortunately, CML has been the epicenter of exciting advances in cancer therapy with the discovery of the Bcr-Abl gene fusion and the subsequent development of imatinib mesylate, a small molecule tyrosine kinase inhibitor, to target the kinase activity of the bcr-abl protein product. Despite unprecedented durability for complete hematologic, cytogenetic, and molecular responses seen with front-line imatinib therapy, many patients require alternative therapy because of drug intolerance, suboptimal response, primary resistance, secondary resistance, or progression to advanced phase disease. Further, up to 5% of patients present with advanced disease that does not sustain a durable response to tyrosine kinase inhibitors. Thus, up to one third of CML patients require alternate therapy. Chronic myeloid leukemia has become an exemplary model system for understanding molecular targeting and overcoming mechanisms of drug resistance. This review will discuss potential mechanisms of resistance and ongoing research into novel targets and agents for CML resistant to standard of care.
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Affiliation(s)
- Sameek Roychowdhury
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI 48109, USA
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45
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Translating Trial-Based Molecular Monitoring Into Clinical Practice: Importance of International Standards and Practical Considerations for Community Practitioners. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:385-95. [DOI: 10.1016/j.clml.2011.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 01/25/2011] [Indexed: 11/29/2022]
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46
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Marin D, Gabriel IH, Ahmad S, Foroni L, de Lavallade H, Clark R, O'Brien S, Sergeant R, Hedgley C, Milojkovic D, Khorashad JS, Bua M, Alsuliman A, Khoder A, Stringaris K, Cooper N, Davis J, Goldman JM, Apperley JF, Rezvani K. KIR2DS1 genotype predicts for complete cytogenetic response and survival in newly diagnosed chronic myeloid leukemia patients treated with imatinib. Leukemia 2011; 26:296-302. [PMID: 21844874 DOI: 10.1038/leu.2011.180] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Natural killer (NK) cells are expanded in chronic myeloid leukemia (CML) patients on tyrosine kinase inhibitors (TKI) and exert cytotoxicity. The inherited repertoire of killer immunoglobulin-like receptors (KIR) may influence response to TKI. We investigated the impact of KIR-genotype on outcome in 166 chronic phase CML patients on first-line imatinib treatment. We validated our findings in an independent patient group. On multivariate analysis, KIR2DS1 genotype (RR=1.51, P=0.03) and Sokal risk score (low-risk RR=1, intermediate-risk RR=1.53, P=0.04, high-risk RR=1.69, P=0.034) were the only independent predictors for failure to achieve complete cytogenetic response (CCyR). Furthermore, KIR2DS1 was the only factor predicting shorter progression-free (PFS) (RR=3.1, P=0.03) and overall survival (OS) (RR=2.6, P=0.04). The association between KIR2DS1 and CCyR, PFS and OS was validated by KIR genotyping in 174 CML patients on first-line imatinib in the UK multi-center SPIRIT-1 trial; in this cohort, KIR2DS1(+) patients had significantly lower 2-year probabilities of achieving CCyR (76.9 vs 87.9%, P=0.003), PFS (85.3 vs 98.1%, P=0.007) and OS (94.4 vs 100%, P=0.015) than KIR2DS1(-) patients. The impact of KIR2DS1 on CCyR was greatest when the ligand for the corresponding inhibitory receptor, KIR2DL1, was absent (P=0.00006). Our data suggest a novel role for KIR-HLA immunogenetics in CML patients on TKI.
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Affiliation(s)
- D Marin
- Department of Hematology, Imperial College London, London, UK
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BCR-ABL kinase domain mutation analysis in chronic myeloid leukemia patients treated with tyrosine kinase inhibitors: recommendations from an expert panel on behalf of European LeukemiaNet. Blood 2011; 118:1208-15. [PMID: 21562040 DOI: 10.1182/blood-2010-12-326405] [Citation(s) in RCA: 367] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mutations in the Bcr-Abl kinase domain may cause, or contribute to, resistance to tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia patients. Recommendations aimed to rationalize the use of BCR-ABL mutation testing in chronic myeloid leukemia have been compiled by a panel of experts appointed by the European LeukemiaNet (ELN) and European Treatment and Outcome Study and are here reported. Based on a critical review of the literature and, whenever necessary, on panelists' experience, key issues were identified and discussed concerning: (1) when to perform mutation analysis, (2) how to perform it, and (3) how to translate results into clinical practice. In chronic phase patients receiving imatinib first-line, mutation analysis is recommended only in case of failure or suboptimal response according to the ELN criteria. In imatinib-resistant patients receiving an alternative TKI, mutation analysis is recommended in case of hematologic or cytogenetic failure as provisionally defined by the ELN. The recommended methodology is direct sequencing, although it may be preceded by screening with other techniques, such as denaturing-high performance liquid chromatography. In all the cases outlined within this abstract, a positive result is an indication for therapeutic change. Some specific mutations weigh on TKI selection.
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48
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Wongboonma W, Thongnoppakhun W, Auewarakul CU. A single-tube allele specific-polymerase chain reaction to detect T315I resistant mutation in chronic myeloid leukemia patients. J Hematol Oncol 2011; 4:7. [PMID: 21303525 PMCID: PMC3045387 DOI: 10.1186/1756-8722-4-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/08/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND BCR-ABL kinase domain (KD) mutation is the major mechanism contributing to suboptimal response to tyrosine kinase inhibitors (TKI) in BCR-ABL-positive chronic myeloid leukemia (CML) patients. T315I mutation, as one of the most frequent KD mutations, has been shown to be strongly associated with TKI resistance and subsequent therapeutic failure. A simple and sensitive method is thus required to detect T315I mutation at the earliest stage. METHODS A single-tube allele specific-polymerase chain reaction (AS-PCR) method was developed to detect T315I mutation in a mixture of normal and mutant alleles of varying dilutions. Denaturing high performance liquid chromatography (DHPLC) and direct sequencing were performed as a comparison to AS-PCR. RESULTS T315I mutant bands were observed in the mixtures containing as low as 0.5-1% of mutant alleles by AS-PCR. The detection sensitivity of DHPLC was around 1.5-3% dilution whereas sequencing analysis was unable to detect below 6.25% dilution. CONCLUSION A single-tube AS-PCR is a rapid and sensitive screening method for T315I mutation. Detection of the most resistant leukemic clone in CML patients undergoing TKI therapy should be feasible with this simple and inexpensive method.
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Affiliation(s)
- Wanwisa Wongboonma
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Garland P, Apperley J. Nilotinib: evaluation and analysis of its role in chronic myeloid leukemia. Future Oncol 2011; 7:201-18. [DOI: 10.2217/fon.10.174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Nilotinib, formally known as AMN107, is a second-generation tyrosine kinase inhibitor, rationally designed from its revolutionary parent compound imatinib, to produce a 30–40-fold enhancement in the inhibition of the BCR–ABL1-derived oncoprotein associated with chronic myeloid leukemia. In clinical trials, nilotinib has proven to be a useful agent in the treatment of imatinib-refractory disease and was initially approved by both the US FDA and EMA in 2007 for use in adults as a second-line therapy. More recently, data from the first randomized controlled trials of the front-line use of nilotinib in newly diagnosed patients with chronic phase chronic myeloid leukemia have demonstrated superiority in the rates of major molecular responses at 12 months over the gold standard–imatinib 400 mg. As such, in June 2010, the FDA granted accelerated approval for its use in newly diagnosed Philadelphia chromosome-positive chronic myeloid leukemia. Nilotinib is well tolerated, with a favorable side-effect profile. With the emergence of supportive trial data, it is likely to have a leading role both in the front-line management of newly presenting patients and in the second-line treatment of patients resistant to or intolerant of imatinib and other second-line agents.
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Affiliation(s)
- Paula Garland
- Department of Hematology, Imperial College London, Hammersmith Hospital, London, UK
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Survivin isoform expression patterns in CML patients correlate with resistance to imatinib and progression, but do not trigger cytolytic responses. Clin Immunol 2011; 139:155-63. [PMID: 21342791 DOI: 10.1016/j.clim.2011.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 12/16/2010] [Accepted: 01/19/2011] [Indexed: 12/11/2022]
Abstract
Tyrosine-kinase inhibitors are very effective in patients with CML, but in most cases the disease relapses after their discontinuation. As a result, novel approaches should be considered, such as anti-survivin treatment or anti-survivin-based immunotherapy. To gain insight into the roles of survivin isoform expression and specific CD8(+) T cells in CML, we investigated 51 patients at different stages, both at diagnosis and during treatment. We demonstrated that (i) patients at advanced-stage displayed an increased expression of the standard-survivin form along with a significant decrease of survivin-2B and -ΔEx3 levels, (ii) patients in chronic phase with higher expression of the standard-survivin exhibited a 3.5-fold increased probability not to achieve an optimal response to imatinib (p=0.048), (iii) responders displayed a significant up-regulation of all survivin isoforms in bone marrow, and (iv) anti-survivin CD8(+) T cells were undetectable both at diagnosis and during treatment. Accordingly, our results question the validity of immunotherapeutic approaches targeting survivin in CML.
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