Imatinib therapy in chronic myeloid leukemia

Imatinib analogs as potential agents for PET imaging of Bcr-Abl and c-KIT expression at a kinase level

We synthesized two series of imatinib mesylate (STI-571) analogs to develop a Bcr-Abl and c-KIT receptor-specific labeling agent for positron emission tomography (PET) imaging to measure Bcr-Abl and c-KIT expression levels in a mouse model. The methods of molecular modeling, synthesis of STI-571 and its analogs, in vitro kinase assays, and radiolabeling are described. Molecular modeling revealed that these analogs bind the same Bcr-Abl and c-KIT binding sites as those bound by STI-571. The analogs potently inhibit the tyrosine kinase activity of Bcr-Abl and c-KIT, similarly to STI-571. [(18)F]-labeled STI-571 was prepared with high specific activity (75 GBq/μmol) by nucleophilic displacement and an average radiochemical yield of 12%. [(131)I]-labeled STI-571 was prepared with high purity (>95%) and an average radiochemical yield of 23%. The uptake rates of [(18)F]-STI-571 in K562 cells expressing Abl and in U87WT cells overexpressing c-KIT were significantly higher than those in the U87 cell and could be inhibited by STI-71 (confirming the specificity of uptake). PET scans of K562 and U87WT tumor-bearing mice with [(18)F]-STI-571 as a contrast agent showed visible tumor uptake and tumor-to-non-target contrast.

A therapeutic drug monitoring algorithm for refining the imatinib trough level obtained at different sampling times

BACKGROUND

Correlation analyses have demonstrated that maintaining an adequate imatinib (IM) trough concentration would be important for clinical response in patients with chronic myeloid leukemia (CML) and Kit-positive gastrointestinal stromal tumors. The objectives of the current work were to use a pharmacokinetic model to refine the trough levels obtained at different sampling times and to propose a therapeutic drug monitoring algorithm and an acceptable sampling time window for imatinib trough sampling.

METHODS

The pharmacokinetics of IM in patients (pts) with CML were characterized based on historical data from a Phase III study. In the elimination phase the concentration of IM (C(t)) follows a mono-exponential decline, and the standardized trough concentration (C(min,std) = C(tau)) can be described by a simple algorithm C(min,std) = C(t)* exp(k(e) x Delta t), where Delta t = t - tau, and tau is 24 hours for qd or 12 hours for bid dosing and k(e) is the elimination rate constant. The percent deviation of C(t) from C(min,std) was simulated for different Delta t and k(e) values to define a sampling time window Delta t, within which the percent deviation is <20%.

RESULTS

Simulation analysis shows that C(t) is largely dependent on Delta t and k(e). The percent deviation of C(t) at 3 hours before or after tau from C(min,std) will be 7.1%, 13.1%, and 23.4% for pts with low, typical, and high k(e) values, 0.023/hour, 0.041/hour, and 0.070/hour, respectively. However, if a correction is made for C(t) by the algorithm using the typical k(e) value of 0.041 per hour, the percent deviation at 3 hours will be reduced to 5.3%, 0%, and 9.1% for pts with low, typical, and high k(e) values, respectively. Even if the sampling window is extended to +/-6 hours, the corresponding percent deviation will still be reasonable: 10.2%, 0%, and 19.0%, respectively.

CONCLUSION

By using the algorithm, the pharmacokinetic sampling window can be extended to a wider window to make the trough sampling easy to implement in the clinical setting, provided that the sampling time and dosing time are accurately recorded.

Pharmacokinetic/pharmacodynamic correlation and blood-level testing in imatinib therapy for chronic myeloid leukemia

Imatinib is the current standard of care in the treatment of chronic myeloid leukemia (CML), inducing durable responses and prolonged progression-free survival. However, plasma exposure to the drug from a given dosing regimen can vary widely among patients. Reasons for this may include incomplete adherence, intrinsic variations in the metabolism of imatinib, and drug-drug interactions. Data from two recent studies have shown a correlation between imatinib trough plasma concentration and clinical response, leading to suggestions that maintaining imatinib blood concentrations above approximately 1000 ng/ml might be associated with improved outcomes. In patients who do not respond as well as expected to initial imatinib treatment, measurement of trough plasma concentration could assist with decisions about whether to increase the dose. Blood-level testing may also be helpful in other clinical scenarios: for example, when poor adherence is suspected, adverse reactions are unusually severe, or there is a possible drug-drug interaction. Further work is required to confirm prospectively the link between imatinib plasma concentrations and response, and to define effective trough concentrations in different patient populations. However, based on the current data, imatinib blood-level testing seems to be a useful aid when making clinical decisions in CML.

Quantitative in situ detection of phosphoproteins in fixed tissues using quantum dot technology

Detection and quantitation of phosphoproteins (PPs) in fixed tissues will become increasingly important as additional inhibitors of protein kinases enter clinical use and new disease entities are defined by molecular changes affecting PP levels. We characterize fixation conditions suitable for accurate PP quantitation that are achievable in a clinical laboratory and illustrate the utility of in situ quantitation of PPs by quantum dot (QD) nanocrystals in two models: (1) a therapeutic model demonstrating effects of a targeted therapeutic (quantitative reduction of phospho-GSK3beta) in xenografts treated with enzastaurin; and (2) a diagnostic model that identifies elevated levels of nuclear phospho-STAT5 in routine bone marrow biopsies from patients with acute myeloid leukemia based on the presence of the activating FLT3-ITD mutation. Finally, we document production of a well-characterized tissue microarray of widely available cell lines as a multilevel calibrator for validating numerous phosphoprotein assays. QD immunofluorescence is an ideal method for in situ quantitation of PPs in fixed samples, providing valuable cell type-specific and subcellular information about pathway activation in primary tissues.

Imatinib pharmacokinetics and its correlation with response and safety in chronic-phase chronic myeloid leukemia: a subanalysis of the IRIS study

Imatinib at 400 mg daily is standard treatment for chronic myeloid leukemia in chronic phase. We here describe the correlation of imatinib trough plasma concentrations (Cmins) with clinical responses, event-free survival (EFS), and adverse events (AEs). Trough level plasma samples were obtained on day 29 (steady state, n = 351). Plasma concentrations of imatinib and its metabolite CGP74588 were determined by liquid chromatography/mass spectrometry. The overall mean (± SD, CV%) steady-state Cmin for imatinib and CGP74588 were 979 ng/mL (± 530 ng/mL, 54.1%) and 242 ng/mL (± 106 ng/mL, 43.6%), respectively. Cumulative estimated complete cytogenetic response (CCyR) and major molecular response (MMR) rates differed among the quartiles of imatinib trough levels (P = .01 for CCyR, P = .02 for MMR). Cmin of imatinib was significantly higher in patients who achieved CCyR (1009 ± 544 ng/mL vs 812 ± 409 ng/mL, P = .01). Patients with high imatinib exposure had better rates of CCyR and MMR and EFS. An exploratory analysis demonstrated that imatinib trough levels were predictive of higher CCyR independently of Sokal risk group. AE rates were similar among the imatinib quartile categories except fluid retention, rash, myalgia, and anemia, which were more common at higher imatinib concentrations. These results suggest that an adequate plasma concentration of imatinib is important for a good clinical response. This study is registered at http://clinicaltrials.gov as NCT00333840.

The impact of comorbid atopic disease on asthma: clinical expression and treatment

Clinically, asthma and allergic rhinitis involve separate regions of the respiratory tract while representing a common underlying inflammatory syndrome. Much evidence supports an epidemiologic association between the diseases, paranasal sinus involvement in both conditions, and parallel relationship in severity and treatment outcomes. Pathophysiologic mechanisms, including immunoglobulin E (IgE)- mediated inflammation, are also shared. Blocking IgE with the recombinant humanized monoclonal antibody omalizumab demonstrated clinical efficacy in patients with upper and lower airway diseases. IgE blockade, leukotriene modulation, and B-cell depletion therapy have all exhibited success in chronic inflammation, reinforcing and expanding the beneficial role of immunomodulation of global mediators.

Advances in the treatment for haematological malignancies

Despite the progress made in the last decade in the treatment of haematological malignancies, most of the patients still have a dismal prognosis. However, the improved knowledge of tumour biology opened the possibility to develop new 'intelligent' therapeutic strategies, the so-named targeted therapies. These approaches aim to selectively kill cancer cells by basing this selectivity on both the expression of a specific molecule on their surface or the activation of particular molecular pathways secondary to malignant transformation. In this article, the authors review the main targeted therapies available in haematology, such as monoclonal antibodies, tyrosine kinase, farnesyltransferase, as well as proteasome inhibitors, antiangiogenesis compounds and antisense oligonuceotides. Finally, the authors focus on the application of imatinib mesylate in chronic myeloid leukaemia as the paradigm of molecular treatment. Although these novel therapies are beginning to fulfil their promise, continued research efforts are needed to determine the optimal role of these strategies in haemato-oncology.

Complex interaction of BCRP/ABCG2 and imatinib in BCR-ABL-expressing cells: BCRP-mediated resistance to imatinib is attenuated by imatinib-induced reduction of BCRP expression

Imatinib, a potent tyrosine kinase inhibitor, is effluxed from cells by the breast cancer resistance protein (BCRP/ABCG2), yet published studies to date fail to demonstrate resistance to imatinib cytotoxicity in BCRP-overexpressing cells in vitro. We investigated cellular resistance to imatinib in BCR-ABL-expressing cells transduced and selected to overexpress BCRP (K562/BCRP-MX10). These cells exhibited a 2- to 3-fold increase in resistance to imatinib (P < .05) and a 7- to 12-fold increase in resistance to mitoxantrone, a known BCRP substrate. Resistance to imatinib was completely abolished by the specific BCRP inhibitor fumitremorgin C. Studies of the mechanism of the diminished resistance to imatinib compared with mitoxantrone revealed that imatinib decreased the expression of BCRP in K562/BCRP-MX10 cells without affecting mRNA levels. BCRP levels in cells that do not express BCR-ABL were not affected by imatinib. Loss of BCRP expression was accompanied by imatinib-induced reduction of phosphorylated Akt in the BCRP-expressing K562 cells. The phosphoinositol-3 kinase (PI3K) inhibitor LY294002 also decreased BCRP levels in K562/BCRP-MX10 cells. These studies show that BCRP causes measurable imatinib resistance, but this effect is attenuated by imatinib-mediated inhibition of BCR-ABL, which in turn downregulates overall BCRP levels posttranscriptionally via the PI3K-Akt pathway.

Calcium/calmodulin-dependent kinase I and calcium/calmodulin-dependent kinase kinase participate in the control of cell cycle progression in MCF-7 human breast cancer cells

Calcium is universally required for cell growth and proliferation. Calmodulin is the main intracellular receptor for calcium. Although calcium and calmodulin are well known to be required for cell cycle regulation, the target pathways for their action remain poorly defined. Potential targets include the calcium/calmodulin-dependent kinases (CaM-K). The aim of this study was to determine the role of the CaM-Ks on cell proliferation and progress through the cell cycle in breast cancer cells. CaM-KI inhibition with either KN-93 or specific interfering RNA (siRNA) caused an arrest in the cell cycle in the human breast cancer cell line, MCF-7. This arrest occurred in the G(1) phase of the cell cycle. Supporting this finding, CaM-K inhibition using KN-93 also resulted in a reduction of cyclin D1 protein and pRb phosphorylation when cells were compared with control cultures. Furthermore, inhibition of the upstream activator of CaM-KI, CaM-KK, using siRNA also resulted in cell cycle arrest. In summary, CaM-KK and CaM-KI participate in the control of the G(0)-G(1) restriction check point of the cell cycle in human breast cancer cells. This arrest seems due to an inhibition in cyclin D1 synthesis and a reduction in pRb phosphorylation. To the best of our knowledge, this is the first time that CaM-KK has been reported to be involved in mammalian cell cycle regulation and that CaM-Ks are regulating breast cancer cell cycle.

Cost-efficacy of imatinib versus allogeneic bone marrow transplantation with a matched unrelated donor in the treatment of chronic myelogenous leukemia: a decision-analytic approach

STUDY OBJECTIVE

To develop and populate a decision-analytic model for comparing the 2-year cost and efficacy of imatinib versus allogeneic bone marrow transplantation (BMT) with a matched unrelated donor in the treatment of a 35-year-old man with newly diagnosed, Philadelphia chromosome-positive (Ph[+]) chronic myelogenous leukemia (CML) in the chronic phase.

DESIGN

Markov cohort analysis and first-order Monte Carlo microsimulation.

MEASUREMENTS AND MAIN RESULTS

Direct medical costs were measured from the perspective of a third-party payer. Efficacy data and probabilities were obtained from survivability findings, most of which were derived from randomized controlled trials. We employed a 2-year time horizon with 3-month treatment cycles. The comparator was BMT with a matched unrelated donor, and the base case was defined as a 35-year-old, Ph(+) man with newly diagnosed CML. The Monte Carlo microsimulation indicated that the incremental cost:efficacy ratio was -$5000 for imatinib (95% confidence interval -$70,000-84,000). Analysis of the cost-efficacy plane revealed that imatinib was dominant over BMT in 84.69% of cases, whereas BMT dominated imatinib in 0.76% of cases. Trade-offs were warranted in the remaining cases. Sensitivity analyses of costs and discount rates found these results to be generally robust.

CONCLUSION

In most cases, imatinib was both less costly and more efficacious than BMT in the 2-year treatment of CML. Results of this investigation should be viewed in the context of emerging long-term clinical data. These data are necessary to assess cost-efficacy beyond the short-term time horizon of this study.