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Tian J, Song YP, Zhang GC, Wang SF, Chu XX, Chai Y, Wang CL, He AL, Zhang F, Shen XL, Zhang WH, Yang LH, Nie DN, Wang DM, Zhu HL, Gao D, Lou SF, Zhou ZP, Su GH, Li Y, Lin JY, Shi QZ, Ouyang GF, Jing HM, Chen SJ, Li J, Mi JQ. Oral arsenic plus imatinib versus imatinib solely for newly diagnosed chronic myeloid leukemia: a randomized phase 3 trial with 5-year outcomes. J Cancer Res Clin Oncol 2024; 150:189. [PMID: 38605258 PMCID: PMC11009770 DOI: 10.1007/s00432-024-05700-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/13/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE The synergistic effects of combining arsenic compounds with imatinib against chronic myeloid leukemia (CML) have been established using in vitro data. We conducted a clinical trial to compare the efficacy of the arsenic realgar-indigo naturalis formula (RIF) plus imatinib with that of imatinib monotherapy in patients with newly diagnosed chronic phase CML (CP-CML). METHODS In this multicenter, randomized, double-blind, phase 3 trial, 191 outpatients with newly diagnosed CP-CML were randomly assigned to receive oral RIF plus imatinib (n = 96) or placebo plus imatinib (n = 95). The primary end point was the major molecular response (MMR) at 6 months. Secondary end points include molecular response 4 (MR4), molecular response 4.5 (MR4.5), progression-free survival (PFS), overall survival (OS), and adverse events. RESULTS The median follow-up duration was 51 months. Due to the COVID-19 pandemic, the recruitment to this study had to be terminated early, on May 28, 2020. The rates of MMR had no significant statistical difference between combination and imatinib arms at 6 months and any other time during the trial. MR4 rates were similar in both arms. However, the 12-month cumulative rates of MR4.5 in the combination and imatinib arms were 20.8% and 10.5%, respectively (p = 0.043). In core treatment since the 2-year analysis, the frequency of MR4.5 was 55.6% in the combination arm and 38.6% in the imatinib arm (p = 0.063). PFS and OS were similar at five years. The safety profiles were similar and serious adverse events were uncommon in both groups. CONCLUSION The results of imatinib plus RIF as a first-line treatment of CP-CML compared with imatinib might be more effective for achieving a deeper molecular response (Chinadrugtrials number, CTR20170221).
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Affiliation(s)
- Jie Tian
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong-Ping Song
- The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | | | | | | | - Ye Chai
- Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Chun-Ling Wang
- The Affiliated Huaian No 1 People's Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Ai-Li He
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Feng Zhang
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Xu-Liang Shen
- Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Wei-Hua Zhang
- The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Lin-Hua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Da-Nian Nie
- The Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | | | - Huan-Ling Zhu
- West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Da Gao
- The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shi-Feng Lou
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ze-Ping Zhou
- The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Guo-Hong Su
- Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Yan Li
- The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jin-Ying Lin
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Qing-Zhi Shi
- The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | | | | | - Sai-Juan Chen
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jian Li
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jian-Qing Mi
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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2
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Claudiani S, Chughtai F, Khan A, Hayden C, Fernando F, Khorashad J, Orovboni V, Scandura G, Innes A, Apperley JF, Milojkovic D. Long-term outcomes after upfront second-generation tyrosine kinase inhibitors for chronic myeloid leukemia: managing intolerance and resistance. Leukemia 2024; 38:796-802. [PMID: 38424138 PMCID: PMC10997507 DOI: 10.1038/s41375-024-02187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
Second-generation tyrosine kinase inhibitors (2GTKI) are more effective in inducing rapid molecular responses than imatinib when used first-line in patients with chronic myeloid leukemia in chronic phase (CML-CP). However, failure of first line-2GTKI (1L-2GTKI) still occurs and there is no consensus regarding subsequent management. We retrospectively analyzed the outcome of 106 CML-CP patients treated with 1L-2GTKI and with a median follow-up of 91 months. 45 patients (42.4%) switched to an alternative TKI, 28 for intolerance (26.4%) and 17 (16%) for resistance. Most patients who remained on 1L-2GTKI achieved deep molecular responses (DMR) and 15 (14.1%) are in treatment-free remission (TFR). Intolerant patients also obtained DMR, although most required multiple TKI changes and were slower to respond, particularly if treated with 2L-imatinib. Inferior outcomes were observed in resistant patients, who failed alternative 2L-2GTKI and required 3/4GTKI and/or allogeneic hematopoietic stem cell transplant (alloSCT). 7yr-OS was significantly lower for these individuals (66.1%) than for intolerant patients and those who remained on 1L-2GTKI (100% and 97.9%, respectively; p = 0.001). It is apparent that failure of 1L-2GTKI is a challenging problem in modern CML therapy. Intolerance can be effectively managed by switching to an alternative 2GTKI, but resistance requires early consideration of 3/4GTKI.
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Affiliation(s)
- Simone Claudiani
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK.
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Farhan Chughtai
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Afzal Khan
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Chloe Hayden
- Imperial Molecular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fiona Fernando
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jamshid Khorashad
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Orovboni
- Imperial Molecular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Glenda Scandura
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Andrew Innes
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jane F Apperley
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Dragana Milojkovic
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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3
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Hijiya N, Mauro MJ. Asciminib in the Treatment of Philadelphia Chromosome-Positive Chronic Myeloid Leukemia: Focus on Patient Selection and Outcomes. Cancer Manag Res 2023; 15:873-891. [PMID: 37641687 PMCID: PMC10460573 DOI: 10.2147/cmar.s353374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have significantly changed the treatment of chronic myeloid leukemia (CML) and improved outcomes for patients with CML in chronic phase (CML-CP) and accelerated phase (AP). Now armed with numerous effective therapeutic options, clinicians must consider various patient- and disease-specific factors when selecting the most appropriate TKI across lines of therapy. While most patients with CML expected to have a near-normal life expectancy due to the success of TKIs, emphasis has expanded beyond response and survival to include factors like quality of life, tolerability, and long-term toxicity management. Importantly, a subset of patients can achieve sustained deep molecular response and can attain treatment-free remission. Despite these successes, unmet needs remain related to CML treatment, including the persistent challenge of treatment resistance and intolerance, broadening treatment options for patients with resistance mutations or serious comorbidities, and focus on specific populations such as children and young adults. In particular, the only previously available treatments for patients with CML-CP with the T315I mutation were ponatinib, olverembatinib (exclusively approved for use in China at the time of this writing), omacetaxine, and hematopoietic stem cell transplantation. Asciminib has entered the CML treatment landscape as a new option for adult patients with CML-CP who have received ≥2 prior TKIs or those with the T315I mutation. Asciminib's unique mechanism of action, Specifically Targeting the ABL Myristoyl Pocket, sets it apart from traditional adenosine triphosphate-competitive TKIs. While asciminib may overcome unmet needs for patients with CML-CP and continues to be studied in other novel settings, guidance on how to integrate asciminib in treatment algorithms is needed. This review focuses on clinical data and how asciminib can overcome current unmet needs, discusses how to individualize patient selection, and highlights future directions to investigate asciminib in earlier lines of therapy and in children and adolescents.
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Affiliation(s)
- Nobuko Hijiya
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael J Mauro
- Myeloproliferative Neoplasms Program, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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4
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Crysandt M, Brümmendorf TH. [Current management and new treatment strategies of chronic myeloid leukemia]. Dtsch Med Wochenschr 2023; 148:744-751. [PMID: 37257476 DOI: 10.1055/a-1941-7438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The introduction of orally available tyrosine kinase inhibitors (TKI) into the treatment of chronic myeloid leukemia (CML) 25 years ago has substantially improved the clinical outcome of affected patients and resulted in a near-normal life expectancy in chronic phase (CP). Despite of a significant fraction of currently about one third of newly diagnosed CP patients eventually reaching treatment-free remission, the majority of patients still remain on life-long treatment with TKIs. Therefore, a profound knowledge of TKI-related side effects including an increased sensitivity for organ systems predominantly involved, grading, kinetics, duration and reversibility, class-effects versus compound-relatedness as well as a better understanding of how particularly long-lasting, chronic, sometimes formally low-grade toxicities can actually significantly impair patient's self-assessed quality of life is of utmost importance for an adequate patient/doctor relationship. Given that nowadays, severity and degree of preexisting comorbidities might predict long-term survival of individual patients more significantly than the underlying CML itself, it becomes most important to properly and thoroughly select the TKI of choice on this basis as well as on the individually required co-medications. Given the variety of 2nd, 3rd and now allosteric TKIs available for the molecular targeting of the disease-driving BCR-ABL oncogene in addition to the "class-defining" Imatinib, personalization of CML therapy should now be further extended towards a better appreciation of comorbidities and co-medications before selection of an individual's TKI treatment complemented by a long-term oriented, patient-centered management and prevention of (sometimes irreversible) TKI side effects.
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Affiliation(s)
- Martina Crysandt
- Klinik für Hämatologie, Onkologie, Hämostaseologie und Stammzelltransplantation, Uniklinik RWTH Aachen, Aachen, Deutschland
- Standort Aachen, Centrum für Integrierte Onkologie Aachen, Bonn, Köln, Düsseldorf (CIO ABCD), aachen
| | - Tim H Brümmendorf
- Klinik für Hämatologie, Onkologie, Hämostaseologie und Stammzelltransplantation, Uniklinik RWTH Aachen, Aachen, Deutschland
- Standort Aachen, Centrum für Integrierte Onkologie Aachen, Bonn, Köln, Düsseldorf (CIO ABCD), aachen
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5
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Dose optimization of tyrosine kinase inhibitor therapy in chronic myeloid leukemia. Int J Hematol 2023; 117:24-29. [PMID: 36087226 DOI: 10.1007/s12185-022-03431-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 01/07/2023]
Abstract
The therapeutic outcomes of chronic myeloid leukemia (CML) have improved dramatically since tyrosine kinase inhibitors (TKIs) became available in clinical practice. Life expectancy of patients with CML is now close to that of the general population. Patients with CML who achieve sustained deep molecular response may discontinue TKI therapy. However, most patients still require TKI therapy for long periods without sustained deep molecular response. Given the awareness of increased incidence of arterial occlusive events in patients on TKI therapy, the optimal TKI selection should be based on age, comorbidities, risk classification, and goals of treatment. Dose optimization of TKI therapy reduces the incidence of adverse events while maintaining efficacy in CML.
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6
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Scalzulli E, Carmosino I, Bisegna ML, Martelli M, Breccia M. CML Resistant to 2nd-Generation TKIs: Mechanisms, Next Steps, and New Directions. Curr Hematol Malig Rep 2022; 17:198-205. [PMID: 36264428 DOI: 10.1007/s11899-022-00683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The clinical scenario for chronic myeloid leukemia patients rapidly changed after the introduction of tyrosine kinase inhibitors (TKIs). Second-generation TKIs as frontline treatment increased the rate of deep molecular responses without increasing the rate of overall survival. About 20% of patients experience resistance to these agents, needing alternative treatments. Here, we reviewed the possible mechanisms of resistance, available treatment, and new drugs developed to counteract and overcome resistance. RECENT FINDINGS Results of novel TKIs have been recently reported, especially for the setting of T315I mutated patients, such as olverembatinib and asciminib, or for patients who developed resistance due to other mutations, such as vodobatinib. Most of new TKIs are selected among compounds tested selective on ABL, therefore without possible off-target effects in the long term. New potential treatments are on the horizon in the field of CML, able to rescue patients treated firstly with one or more second-generation TKIs. Results of ongoing trials and real-world evidence dataset will help us to identify the appropriate timing of intervention and to select appropriate candidate to these drugs.
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Affiliation(s)
- Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Maria Laura Bisegna
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Via Benevento 6, 00161, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I-Sapienza University, Via Benevento 6, 00161, Rome, Italy.
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7
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Wu Q, Kang Y, Xu J, Ye WC, Li ZJ, He WF, Song Y, Wang QM, Tang AP, Zhou T. Sudden extramedullary and extranodal Philadelphia-positive anaplastic large-cell lymphoma transformation during imatinib treatment for CML: A case report. World J Clin Cases 2022; 10:10339-10345. [PMID: 36246839 PMCID: PMC9561565 DOI: 10.12998/wjcc.v10.i28.10339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/18/2022] [Accepted: 08/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic myeloid leukemia (CML) is a malignant hematologic malignancy that can progress to blast phase with a myeloid or lymphoid phenotype. Some patients with CML can also progress to blast crisis phase; however, the transformation of CML into Philadelphia-positive lymphoma is extremely rare.
CASE SUMMARY We present a patient with CML who experienced a sudden transformation to anaplastic large-cell lymphoma (ALCL) after 7 mo of treatment with imatinib, during which she had achieved partial cytogenetic response as well as early molecular response. The patient noticed a mass in her left shoulder, the biopsy data of which were consistent with ALCL; moreover, her lymphoma cells exhibited BCR-ABL gene fusion. The patient was diagnosed with Philadelphia-positive ALCL that progressed from CML, and was thus treated with the second generation tyrosine kinase inhibitor nilotinib. Six months later, the mass had totally disappeared and the BCR-ABL fusion gene was undetectable in the peripheral blood. To our knowledge, this is the first patient known to have developed Philadelphia-positive ALCL transformed from CML.
CONCLUSION Unexplained lymphadenopathy or an extramedullary mass in a patient with CML may warrant a biopsy and testing for BCR-ABL fusion.
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Affiliation(s)
- Qiong Wu
- Department of Clinical Laboratory, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yong Kang
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Hematology, Pingxiang People's hospital, Pingxiang 337000, Jiangxi Province, China
| | - Jing Xu
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Wen-Can Ye
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Hematology, The First Affiliated Hospital of Gannan Medical University, Ganzhou 341001, Jiangxi Province, China
| | - Zhen-Jiang Li
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Wen-Feng He
- Key laboratory of Molecular Medicine of Jiangxi, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yuan Song
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qing-Ming Wang
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ai-Ping Tang
- Department of Hematology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ting Zhou
- Department of Pathology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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8
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Huuhtanen J, Ilander M, Yadav B, Dufva OM, Lähteenmäki H, Kasanen T, Klievink J, Olsson-Strömberg U, Stentoft J, Richter J, Koskenvesa P, Höglund M, Söderlund S, Dreimane A, Porkka K, Gedde-Dahl T, Gjertsen BT, Stenke L, Myhr-Eriksson K, Markevärn B, Lübking A, Dimitrijevic A, Udby L, Bjerrum OW, Hjorth-Hansen H, Mustjoki S. IFN-α with dasatinib broadens the immune repertoire in patients with chronic-phase chronic myeloid leukemia. J Clin Invest 2022; 132:152585. [PMID: 36047494 PMCID: PMC9433106 DOI: 10.1172/jci152585] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/07/2022] [Indexed: 11/24/2022] Open
Abstract
In chronic myeloid leukemia (CML), combination therapies with tyrosine kinase inhibitors (TKIs) aim to improve the achievement of deep molecular remission that would allow therapy discontinuation. IFN-α is one promising candidate, as it has long-lasting effects on both malignant and immune cells. In connection with a multicenter clinical trial combining dasatinib with IFN-α in 40 patients with chronic-phase CML (NordCML007, NCT01725204), we performed immune monitoring with single-cell RNA and T cell receptor (TCR) sequencing (n = 4, 12 samples), bulk TCRβ sequencing (n = 13, 26 samples), flow cytometry (n = 40, 106 samples), cytokine analyses (n = 17, 80 samples), and ex vivo functional studies (n = 39, 80 samples). Dasatinib drove the immune repertoire toward terminally differentiated NK and CD8+ T cells with dampened functional capabilities. Patients with dasatinib-associated pleural effusions had increased numbers of CD8+ recently activated effector memory T (Temra) cells. In vitro, dasatinib prevented CD3-induced cell death by blocking TCR signaling. The addition of IFN-α reversed the terminally differentiated phenotypes and increased the number of costimulatory intercellular interactions and the number of unique putative epitope-specific TCR clusters. In vitro IFN-α had costimulatory effects on TCR signaling. Our work supports the combination of IFN-α with TKI therapy, as IFN-α broadens the immune repertoire and restores immunological function.
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Affiliation(s)
- Jani Huuhtanen
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland.,Department of Computer Science, Aalto University, Espoo, Finland
| | - Mette Ilander
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Bhagwan Yadav
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Olli Mj Dufva
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Hanna Lähteenmäki
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Tiina Kasanen
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Jay Klievink
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Ulla Olsson-Strömberg
- Department of Medical Sciences, Uppsala University and Hematology Section, Uppsala University Hospital, Uppsala, Sweden
| | - Jesper Stentoft
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Johan Richter
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Perttu Koskenvesa
- Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland
| | - Martin Höglund
- Department of Medical Sciences, Uppsala University and Hematology Section, Uppsala University Hospital, Uppsala, Sweden
| | - Stina Söderlund
- Department of Medical Sciences, Uppsala University and Hematology Section, Uppsala University Hospital, Uppsala, Sweden
| | - Arta Dreimane
- Department of Medical and Health Sciences, Linköping University, Department of Hematology, County Council of Östergötland, Linköping, Sweden
| | - Kimmo Porkka
- Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland.,iCAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland
| | - Tobias Gedde-Dahl
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Björn T Gjertsen
- Department of Internal Medicine, Hematology Section, Haukeland University Hospital and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Leif Stenke
- Department of Hematology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | - Berit Markevärn
- Department of Hematology, Umeå University Hospital, Umeå, Sweden
| | - Anna Lübking
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Lene Udby
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Ole Weis Bjerrum
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Henrik Hjorth-Hansen
- Department of Hematology, St. Olavs Hospital, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Satu Mustjoki
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland.,Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Department of Hematology, Helsinki, Finland.,iCAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland
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9
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Lipton JH, Brümmendorf TH, Gambacorti-Passerini C, Garcia-Gutiérrez V, Deininger MW, Cortes JE. Long-term safety review of tyrosine kinase inhibitors in chronic myeloid leukemia - What to look for when treatment-free remission is not an option. Blood Rev 2022; 56:100968. [DOI: 10.1016/j.blre.2022.100968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/14/2022]
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10
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Development of Therapy Approach in Patient with Chronic Granulocity Leukemia: Case Report. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2018-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Chronic granulocytic leukemia (CGL), Ph + is a chronic myeloproliferative disorder, which, due to its specificity for many decades, has attracted the attention of researchers of specialties. This disease was among the first malignant haemopathies that received their “ID card” since molecular precisely defined the basic pathological substrate, that origin of the disease. Over the past decades we have witnessed the evolution of the therapeutic approach in the treatment of from oral cystostatic therapy, radiotherapy, through recombinant interferon alpha (IFN-alpha), haematopoeza stem cell transplantation, to the targeted molecular therapy of the tyrosine inhibitor (TKI).
In this report we present patient with a diagnosis of Ph + in the early chronic phase at the age of 13 all relevant analyzes. During the past 26 years, all modalities of CGL treatment were applied in patients, according to the time period, concluding with the second generation resulting in complete remission of diseases with excellent quality of life and identical expectations for the future, as well as in healthy population.
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11
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Hwang WL, Chen TC, Lin HY, Chang MC, Hsiao PC, Bai LY, Kuo CY, Chen YC, Liu TC, Gau JP, Wang PN, Hwang WS, Kuo MC, Liu CY, Liu YC, Ma MC, Su NW, Wang CC, Wu YY, Yao M, Yeh SP, Cheng HW, Lee YM, Ku FC, Tang JL. NOVEL-1st: an observational study to assess the safety and efficacy of nilotinib in newly diagnosed patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase in Taiwan. Int J Hematol 2022; 115:704-712. [PMID: 35212915 DOI: 10.1007/s12185-022-03311-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
Nilotinib has been approved for the treatment of Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase (Ph+ CML-CP). However, the real-world evidence of nilotinib in newly diagnosed untreated Ph+ CML-CP is limited in Taiwan. The NOVEL-1st study was a non-interventional, multi-center study collecting long-term safety and effectiveness data in patients with newly diagnosed and untreated Ph+ CML-CP receiving nilotinib. We enrolled 129 patients from 11 hospitals. Overall, 1,466 adverse events (AEs) were reported; among these, 151 were serious and 524 were nilotinib-related. Common hematological AEs were thrombocytopenia (31.0%), anemia (20.9%), and leukopenia (14.0%); common nilotinib-related AEs were thrombocytopenia (29.5%), anemia (14.7%), and leukopenia (12.4%). Early molecular response, defined as BCR-ABL ≤ 10% at Month 3, was seen in 87.6% of patients. By 36 months, the cumulative rates of complete hematologic response, complete cytogenetic response, major molecular response, molecular response 4.0-log reduction, and molecular response 4.5-log reduction were 98.5, 92.5, 85.8, 65.0, and 45.0%, respectively. Nilotinib is effective and well-tolerated in patients with newly diagnosed Ph+ CML-CP in the real-world setting. Long-term holistic care and a highly tolerable AE profile may contribute to good treatment outcomes in Ph+ CML-CP under first-line treatment with nilotinib.
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Affiliation(s)
- Wen-Li Hwang
- Taichung Veterans General Hospital, Taichung, Taiwan.,Asia University Hospital, Taichung, Taiwan
| | | | | | | | | | - Li-Yuan Bai
- China Medical University Hospital, Taichung, Taiwan
| | - Ching-Yuan Kuo
- Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | | | - Ta-Chih Liu
- Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.,Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Jyh-Pyng Gau
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Nan Wang
- Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Shou Hwang
- Chung Shan Medical University Hospital, Taichung, Taiwan
| | | | - Chun-Yu Liu
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chang Liu
- Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Chun Ma
- Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Nai-Wen Su
- Mackay Memorial Hospital, Taipei, Taiwan
| | | | - Yi-Ying Wu
- Tri-Service General Hospital, Taipei, Taiwan
| | - Ming Yao
- National Taiwan University Hospital, Taipei, Taiwan
| | - Su-Peng Yeh
- China Medical University Hospital, Taichung, Taiwan
| | | | | | | | - Jih-Luh Tang
- National Taiwan University Hospital, Taipei, Taiwan.
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12
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Singh R, Kapoor J, Ahmed R, Mehta P, Khushoo V, Agrawal P, Bhurani D, Agrawal N. A Retrospective Cohort Study of Upfront Nilotinib in Chronic Myeloid Leukemia: A Single-Center Experience. South Asian J Cancer 2022; 10:246-250. [PMID: 34984204 PMCID: PMC8719978 DOI: 10.1055/s-0041-1733301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context
Nilotinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor used in the treatment of chronic myeloid leukemia (CML).
Aims
We aim to evaluate the responses and safety of upfront Nilotinib therapy in Indian CML patients.
Setting and Design
We retrospectively reviewed the medical records of CML patients who received Nilotinib as an upfront treatment at our center between January 1, 2011 and October 15, 2019.The follow-up was taken till March 31, 2020.
Results
Forty One patients (
n
= 36 chronic phase and five accelerated-phase CML) received frontline Nilotinib. Median age was 39 years (21–63) with male-to-female ratio of 1.1: 1. At 3 months, 96.9% patients achieved BCR-ABL of ≤10% at international scale. By the end of 12 months, 71.5% patients achieved major molecular response (BCR-ABL ≤0.1%) and 91.4% patients achieved complete cytogenetic response assessed by BCR-ABL polymerase chain reaction of ≤1%. Common toxicities observed were weight gain, thrombocytopenia, corrected QT prolongation, and elevated serum amylase in 14 (34.1%), 7(17.07%), 4(9.7%), and 4(9.7%) patients, respectively. Overall, five patients had loss of response with further progression and death in three patients. At a median of 43.7 months, 38 patients survived with estimated 3 year event-free survival and overall survival of 65 ± 9 and 93 ± 5%.
Conclusion
This study showed remarkable good response with upfront Nilotinib in Indian patients with CML.
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Affiliation(s)
- Reema Singh
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Jyotsna Kapoor
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Rayaz Ahmed
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Pallavi Mehta
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Vishvdeep Khushoo
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Pragya Agrawal
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Dinesh Bhurani
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Narendra Agrawal
- Department of Hemato-Oncology and Bone Marrow Transplantation Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
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Cortes J, Pavlovsky C, Saußele S. Chronic myeloid leukaemia. Lancet 2021; 398:1914-1926. [PMID: 34425075 DOI: 10.1016/s0140-6736(21)01204-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 01/04/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Tyrosine-kinase inhibitors have changed the natural history of chronic myeloid leukaemia in such a way that patients with adequate access to these agents, who are properly managed, and who respond well to this treatment can expect a near-normal life expectancy. Achieving this goal requires an adequate understanding of the patient's treatment goals, careful monitoring for the achievement of optimal response hallmarks, implementation of proper interventions according to the attainment of such endpoints, adequate recognition and management of adverse events, and acknowledgment of the relevance of comorbidities. Treatment with tyrosine-kinase inhibitors, once considered lifelong, has become terminable for at least some patients, and promising new agents are emerging for those whose disease does not respond to any of the multiple therapeutic options currently available. If these advances reach all patients with chronic myeloid leukaemia, cure might eventually become a reality in most instances.
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Affiliation(s)
- Jorge Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, USA.
| | | | - Susanne Saußele
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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Castagnetti F, Binotto G, Capodanno I, Billio A, Calistri E, Cavazzini F, Crugnola M, Gozzini A, Gugliotta G, Krampera M, Lucchesi A, Merli A, Miggiano MC, Minotto C, Poggiaspalla M, Salvucci M, Scappini B, Tiribelli M, Trabacchi E, Rosti G, Galimberti S, Bonifacio M. Making Treatment-Free Remission (TFR) Easier in Chronic Myeloid Leukemia: Fact-Checking and Practical Management Tools. Target Oncol 2021; 16:823-838. [PMID: 34661826 PMCID: PMC8613078 DOI: 10.1007/s11523-021-00831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
In chronic-phase chronic myeloid leukemia (CML), tyrosine kinase inhibitors (TKIs) are the standard of care, and treatment-free remission (TFR) following the achievement of a stable deep molecular response (DMR) has become, alongside survival, a primary goal for virtually all patients. The GIMEMA CML working party recently suggested that the possibility of achieving TFR cannot be denied to any patient, and proposed specific treatment policies according to the patient's age and risk. However, other international recommendations (including 2020 ELN recommendations) are more focused on survival and provide less detailed suggestions on how to choose first and subsequent lines of treatment. Consequently, some grey areas remain. After literature review, a panel of Italian experts discussed the following controversial issues: (1) early prediction of DMR and TFR: female sex, non-high disease risk score, e14a2 transcript and early MR achievement have been associated with stable DMR, but the lack of these criteria is not sufficient to exclude any patient from TFR; (2) criteria for first and subsequent line therapy choice: a number of patient and drug characteristics have been proposed to make a personalized decision; (3) monitoring of residual disease after discontinuation: after the first 6 months, the frequency of molecular tests can be reduced based on MR4.5 persistence and short turnaround time; (4) prognosis of TFR: therapy and DMR duration are important to predict TFR; although immunological control of CML plays a role, no immunological predictive phenotype is currently available. This guidance is intended as a practical tool to support physicians in decision making.
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Affiliation(s)
- Fausto Castagnetti
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy.
| | - Gianni Binotto
- Hematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Isabella Capodanno
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Atto Billio
- Hematology and Bone Marrow Transplantation, Ospedale di Bolzano, Bolzano, Italy
| | | | | | - Monica Crugnola
- Hematology Unit and BMT, Azienda Ospedaliero Universitaria, Parma, Italy
| | - Antonella Gozzini
- Department of Cellular Therapies and Transfusion Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gabriele Gugliotta
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mauro Krampera
- Section of Hematology and Bone Marrow Transplant Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Anna Merli
- Hematology Unit, Ospedale Infermi Rimini, AUSL Romagna, Rimini, Italy
| | | | - Claudia Minotto
- Medical Oncology and Onco-Hematology Unit, AULSS 3 Serenissima distretto di Dolo-Mirano, Venice, Italy
| | - Monica Poggiaspalla
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Marzia Salvucci
- Hematology Unit, Oncology and Hematology Department, Ospedale Civico, Ravenna, Italy
| | - Barbara Scappini
- Hematology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medical Area, University of Udine, Udine, Italy
| | - Elena Trabacchi
- Hematology Unit and BMT Center, Ospedale G. Saliceto, Piacenza, Italy
| | - Gianantonio Rosti
- Scientific Direction, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, FC, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimiliano Bonifacio
- Section of Hematology and Bone Marrow Transplant Unit, Department of Medicine, University of Verona, Verona, Italy
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15
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Mulas O, Caocci G, Mola B, La Nasa G. Arterial Hypertension and Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:674748. [PMID: 34630076 PMCID: PMC8493251 DOI: 10.3389/fphar.2021.674748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/03/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Off-target effects in chronic myeloid leukemia (CML) patients treated with tyrosine kinase inhibitors (TKIs) are associated with cardiovascular toxicity. Hypertension represents an important cardiovascular complication and, if not appropriately managed, can contribute to developing thrombotic events. Third-generation TKI ponatinib is associated with hypertension development, and its use is more restricted than in the past. Few data are reported for second-generation TKI, nilotinib, dasatinib, and bosutinib. The aim of this article was to evaluate with a systematic review and meta-analysis the real incidence of hypertension in CML patients treated with second- or third-generation TKI. Methods: The PubMed database, Web of Science, Scopus, and ClinicalTrials.gov were systematically searched for studies published between January 1, 2000, and January 30, 2021; the following terms were entered in the database queries: Cardiovascular, Chronic Myeloid Leukemia, CML, Tyrosine kinases inhibitor, TKI, and Hypertension. The study was carried out according to the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) statement. Results: A pooled analysis of hypertension incidence was 10% for all new-generation TKI, with an even higher prevalence with ponatinib (17%). The comparison with the first-generation imatinib confirmed that nilotinib was associated with a significantly increased risk of hypertension (RR 2; 95% CI; 1.39-2.88, I2=0%, z=3.73, p=0.0002). The greatest risk was found with ponatinib (RR 9.21; 95% CI; 2.86-29.66, z=3.72, p=0.0002). Conclusion: Hypertension is a common cardiovascular complication in CML patients treated with second- or third-generation TKI.
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Affiliation(s)
- Olga Mulas
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Brunella Mola
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giorgio La Nasa
- Hematology Unit, Businco Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Prenggono MD, Yasmina A, Ariyah M, Wanahari TA, Hasrianti N. The effect of imatinib and nilotinib on blood calcium and blood potassium levels in chronic myeloid leukemia patients: a literature review. Oncol Rev 2021; 15:547. [PMID: 34976304 PMCID: PMC8649642 DOI: 10.4081/oncol.2021.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022] Open
Abstract
Imatinib and nilotinib are first-line treatments for chronic myeloid leukemia (CML) patients, which act specifically against target cells. However, these drugs may cause side effects, such as electrolyte disturbances. This literature review aimed to provide a comparison of the effects of imatinib and nilotinib on blood potassium and calcium levels. It also summarized their hypothetical mechanism. A comprehensive electronic search of the different databases was conducted using ‘chronic myeloid leukemia’, ‘tyrosine kinase inhibitors’, ‘imatinib’, ‘nilotinib’, ‘potassium’, ‘calcium’, ‘electrolytes’ as keywords. This review used PubMed- MEDLINE, Cochrane Library, and Google Scholar as the source databases. Sixteen articles published from 2006 to 2020 were reviewed. Changes in blood potassium levels range from increased to decreased levels, while changes in blood calcium levels range from the lower normal values to below normal values (hypocalcemia). Tyrosine kinase inhibitors (TKIs), including imatinib and nilotinib, have a non-specific target, namely plateletderived growth factor receptor (PDGFR), which indirectly affects blood potassium and calcium levels in CML patients. The clinical manifestations of these changes vary from being visible only in laboratory tests to displaying a variety of clinical signs and symptoms.
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Affiliation(s)
- Muhammad Darwin Prenggono
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Faculty of Medicine, Universitas Lambung Mangkurat/Ulin General Hospital, Banjarmasin
| | - Alfi Yasmina
- Department of Pharmacology, Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin
| | - Misna Ariyah
- Medical Education Study Program, Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin
| | - Tenri Ashari Wanahari
- Department of Internal Medicine, Faculty of Medicine, Universitas Lambung Mangkurat/Ulin General Hospital, Banjarmasin, Indonesia
| | - Nuvita Hasrianti
- Department of Internal Medicine, Faculty of Medicine, Universitas Lambung Mangkurat/Ulin General Hospital, Banjarmasin, Indonesia
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Why chronic myeloid leukaemia cannot be cured by tyrosine kinase-inhibitors. Leukemia 2021; 35:2199-2204. [PMID: 34002028 DOI: 10.1038/s41375-021-01272-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 01/29/2023]
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18
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Wang Z, Jiang L, Yan H, Xu Z, Luo P. Adverse events associated with nilotinib in chronic myeloid leukemia: mechanisms and management strategies. Expert Rev Clin Pharmacol 2021; 14:445-456. [PMID: 33618586 DOI: 10.1080/17512433.2021.1894129] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction: Nilotinib is a second-generation tyrosine kinase inhibitor (TKI) targeting BCR/ABL, which is used for the first-line treatment of newly diagnosed chronic myeloid leukemia (CML) patients and the second-line treatment of most CML patients who are resistant or intolerant to prior therapy that includes imatinib. In addition to common adverse reactions, long-term use of nilotinib shows some toxicities that are different from those of occurring during other BCR/ABL TKI treatments, such as cardiovascular toxicity. It is life-threatening, which would affect not only the choice of initial treatment of CML patients but also the safety of long-term medication.Areas covered: Through searching literature and reports from PubMed and clinical trials, here we review a profile of the adverse effects induced by nilotinib. We also discuss the potential molecular toxicological mechanisms and clinical management, which may provide strategies to prevent or intervene the toxicity associated with nilotinib.Expert opinion: Severe adverse effects associated with nilotinib limit its long-term clinical application. However, the exact mechanisms underlying these toxicities remain unclear. Future research should focus on the developing strategies to reduce the toxicities of nilotinib as well as to avoid similar toxicity in the development of new drugs.
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Affiliation(s)
- Zeng Wang
- Department of Colorectal Pharmacy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, China
| | - Liyu Jiang
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Hao Yan
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Zhifei Xu
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Peihua Luo
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
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Aisyi M, Syarif AH, Asih N, Kosasih A. Tyrosine kinase inhibitor resistance in pediatric chronic myeloid leukemia: a case report. MEDICAL JOURNAL OF INDONESIA 2020. [DOI: 10.13181/mji.cr.203765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Pediatric chronic myeloid leukemia (CML) is a hematopoietic malignancy, treated by tyrosine kinase inhibitor (TKI). Previously, imatinib resistance in CML was treated with nilotinib as a second line. However, in Indonesia, where the options of TKIs are limited, no case has been reported. We describe TKI-resistance of a pediatric CML case in Dharmais Cancer Hospital, Jakarta. A 17-year-old boy presented with loss of complete hematologic response after 4 years of imatinib treatment. Diagnosis of relapsed CML with blast crisis was confirmed, and nilotinib was given accordingly. He achieved hematological and optimal response after 2 weeks and 3 months of treatment, respectively. However, in the 12-month evaluation, he failed to achieve major molecular response and acquired the second resistance to TKI. Since imatinib resistance marks the poor prognosis, initial optimal response of nilotinib treatment remains inconclusive to predict the final outcome.
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20
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Stagno F, Breccia M, Di Raimondo F. On the road to treatment-free remission in chronic myeloid leukemia: what about 'the others'? Expert Rev Anticancer Ther 2020; 20:1075-1081. [PMID: 32985290 DOI: 10.1080/14737140.2020.1829483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The treatment of chronic myeloid leukemia (CML) has been drastically changed by the approval of tyrosine kinase inhibitors (TKIs). CML is now managed as a chronic disease requiring both long-term treatment and close molecular monitoring in the majority of patients. AREAS COVERED Evidence suggests that in a substantial number of patients who have achieved a stable deep molecular response (DMR), TKI treatment can be safely discontinued without loss of response. Therefore, treatment-free remission (TFR), through the achievement of a DMR, is increasingly regarded as a feasible treatment goal in about 20% to 40% CML patients. Nevertheless, a proportion of patients with chronic-phase CML treated with TKIs remain in stable MMR and do not achieve a DMR. EXPERT OPINION We provide prospective views on how it is possible to optimize treatment for patients in stable MMR but not in DMR in order to finalize the therapeutic strategy.
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Affiliation(s)
- Fabio Stagno
- Hematology Section and BMT Unit, Rodolico Hospital, AOU Policlinico - V. Emanuele , Catania, Italy
| | - Massimo Breccia
- Hematology, Department of Precision and Translational Medicine, Policlinico Umberto 1, Sapienza University , Rome, Italy
| | - Francesco Di Raimondo
- Hematology Section and BMT Unit, Rodolico Hospital, AOU Policlinico - V. Emanuele , Catania, Italy
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21
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Managing chronic myeloid leukemia for treatment-free remission: a proposal from the GIMEMA CML WP. Blood Adv 2020; 3:4280-4290. [PMID: 31869412 DOI: 10.1182/bloodadvances.2019000865] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022] Open
Abstract
Several papers authored by international experts have proposed recommendations on the management of BCR-ABL1+ chronic myeloid leukemia (CML). Following these recommendations, survival of CML patients has become very close to normal. The next, ambitious, step is to bring as many patients as possible into a condition of treatment-free remission (TFR). The Gruppo Italiano Malattie EMatologiche dell'Adulto (GIMEMA; Italian Group for Hematologic Diseases of the Adult) CML Working Party (WP) has developed a project aimed at selecting the treatment policies that may increase the probability of TFR, taking into account 4 variables: the need for TFR, the tyrosine kinase inhibitors (TKIs), the characteristics of leukemia, and the patient. A Delphi-like method was used to reach a consensus among the representatives of 50 centers of the CML WP. A consensus was reached on the assessment of disease risk (EUTOS Long Term Survival [ELTS] score), on the definition of the most appropriate age boundaries for the choice of first-line treatment, on the choice of the TKI for first-line treatment, and on the definition of the responses that do not require a change of the TKI (BCR-ABL1 ≤10% at 3 months, ≤1% at 6 months, ≤0.1% at 12 months, ≤0.01% at 24 months), and of the responses that require a change of the TKI, when the goal is TFR (BCR-ABL1 >10% at 3 and 6 months, >1% at 12 months, and >0.1% at 24 months). These suggestions may help optimize the treatment strategy for TFR.
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22
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Heibl S, Buxhofer-Ausch V, Schmidt S, Webersinke G, Lion T, Piringer G, Kuehr T, Wolf D, Melchardt T, Greil R, Thaler J. A phase 1 study to evaluate the feasibility and efficacy of the addition of ropeginterferon alpha-2b to imatinib treatment in patients with chronic phase chronic myeloid leukemia (CML) not achieving a deep molecular response (molecular remission 4.5)-AGMT_CML 1. Hematol Oncol 2020; 38:792-798. [PMID: 32757230 DOI: 10.1002/hon.2786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 12/12/2022]
Abstract
The goal of current management of patients with chronic phase chronic myeloid leukemia (CML) is to reach treatment-free remission with sustained deep molecular remission (DMR) being the prerequisite therefor. Second-generation tyrosine kinase inhibitors can induce deeper and faster remission than imatinib, but are often associated with severe adverse events (AEs). The combination of pegylated interferon (IFN) with imatinib was shown to induce higher molecular remissions than imatinib alone in two studies. Treatment discontinuation rates due to IFN induced AEs were high in both studies. To investigate safety, tolerability (primary objective), and efficacy (secondary objective) of the combination of imatinib with ropeginterferon alpha-2b this phase I study was initiated. Twelve patients were planned to be enrolled. Nine patients completed the study according to protocol. Three patients terminated the study early, one due to occurrence of a dose-limiting toxicity (neutropenia grade 3), one due to an AE (panic attacks grade 2) and one due to the patient's decision. Tolerability was good, non-hematologic AEs were mainly grade 1/2, hematologic AEs were mainly neutropenias. No new AEs were reported for the combination of imatinib and ropeginterferon alpha-2b. In a nondose-dependent manner the addition of ropeginterferon alpha-2b led to the achievement of a DMR in four out of nine patients after a treatment duration of 18 months. The combination of imatinib and ropeginterferon alpha-2b is safe and showed in this phase I study the ability to deepen the molecular response in patients with chronic phase CML not achieving a DMR with imatinib alone.
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Affiliation(s)
- Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Hematology, Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz GmbH Elisabethinen, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Stefan Schmidt
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Gerald Webersinke
- Labor für Molekulargenetische Diagnostik, Ordensklinikum Linz GmbH Barmherzige Schwestern, Linz, Austria
| | - Thomas Lion
- Labdia Labordiagnostik GmbH, Children's Cancer Research Institute, Vienna, Austria
| | - Gudrun Piringer
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Thomas Kuehr
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Dominik Wolf
- Department of Internal Medicine V (Hematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Thomas Melchardt
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria.,Salzburg Cancer Research Institute, Center for Clinical Cancer and Immunology Trials (SCRI-CCCIT), Cancer Cluster Salzburg, Salzburg, Austria
| | - Richard Greil
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University, Salzburg, Austria.,Salzburg Cancer Research Institute, Center for Clinical Cancer and Immunology Trials (SCRI-CCCIT), Cancer Cluster Salzburg, Salzburg, Austria
| | - Josef Thaler
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
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23
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Stuckey R, Casado LF, Colomer D, Gómez-Casares MT, Casas L, García-Gutierrez V, Sastre JL, Ramírez-Payer Á, Vall-Llovera F, Goñi MÁ, Xicoy B, Godoy AC, Núñez J, Mora I, Vallansot R, López-Lorenzo JL, Palomera L, Conesa V, Noya MS, Sánchez-Guijo F, Peña A, Bautista G, Steegmann JL. Early Prediction of Subsequent Molecular Response to Nilotinib in Patients with Chronic Myeloid Leukemia: Comparison of the Quantification of BCR-ABL1 Ratios Using ABL1 or GUSB Control Genes. J Mol Diagn 2020; 22:1217-1224. [PMID: 32688056 DOI: 10.1016/j.jmoldx.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 06/19/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022] Open
Abstract
Molecular monitoring of BCR-ABL1 transcripts is a critical prognostic indicator of treatment response in chronic myeloid leukemia (CML). Quantification of BCR-ABL1 transcripts using ABL1 or GUSB as control genes on the early molecular response (MR) to frontline nilotinib was studied using data from 60 patients with chronic-phase CML from the Evaluating Nilotinib Efficacy and Safety in Clinical Trials as First-Line Treatment (ENEST1st) substudy. Effects of BCR-ABL1/ABL1 and BCR-ABL1/GUSB ratios at early time points as independent variables on subsequent MR were determined by logistic regression analyses and predictive cut-off values determined by receiver operating curve analyses. From day 45, concordance was found for both control genes' early transcript kinetics and ability to predict subsequent deep MR at 18 months. From baseline to 3 months, transcripts descended linearly with both control genes. Use of ABL1 allowed for an earlier prediction (2 months) of subsequent MR than with GUSB (3 months), with cut-off values of 1.5% and 0.19%, respectively. The dynamic determination of BCR-ABL1 transcripts using either internal control gene is valid and predictive of subsequent MR. The use of GUSB to predict an earlier and more accurate response than ABL1 is not supported in the results. Accurate early indicators of MR are essential to identify patients likely to have inferior outcomes who may benefit from treatment with an alternative tyrosine kinase inhibitor.
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Affiliation(s)
- Ruth Stuckey
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Dolors Colomer
- Hematopathology Unit, Hospital Clinic Universitari, Barcelona, Spain
| | - María Teresa Gómez-Casares
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - José Luis Sastre
- Department of Hematology, Hospital Universitario de Orense, Orense, Spain
| | - Ángel Ramírez-Payer
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ferrán Vall-Llovera
- Department of Hematology, Hospital Universitari Mútua Terrassa, Terrassa, Spain
| | - María Ángeles Goñi
- Department of Hematology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Blanca Xicoy
- Department of Hematology, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | - Javier Núñez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Itxaso Mora
- Department of Hematology, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Rolando Vallansot
- Hematology Service, Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | - Luis Palomera
- Aragón Institute of Health Investigation, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Venancio Conesa
- Department of Hematology, Hospital General Universitario de Elche, Elche, Spain
| | - María Soledad Noya
- Department of Hematology, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Fermín Sánchez-Guijo
- Department of Hematology, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Ascensión Peña
- Department of Hematology, Hospital Clínico de San Carlos, Madrid, Spain
| | - Guiomar Bautista
- Department of Hematology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
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24
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Davis JS, Ferreira D, Paige E, Gedye C, Boyle M. Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:e00035-19. [PMID: 32522746 PMCID: PMC7289788 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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Affiliation(s)
- Joshua S Davis
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Ferreira
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia
| | - Craig Gedye
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Oncology, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Michael Boyle
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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25
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Annunziata M, Bonifacio M, Breccia M, Castagnetti F, Gozzini A, Iurlo A, Pregno P, Stagno F, Specchia G. Current Strategies and Future Directions to Achieve Deep Molecular Response and Treatment-Free Remission in Chronic Myeloid Leukemia. Front Oncol 2020; 10:883. [PMID: 32582549 PMCID: PMC7280484 DOI: 10.3389/fonc.2020.00883] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/05/2020] [Indexed: 12/21/2022] Open
Abstract
The treatment of chronic myeloid leukemia (CML) has been radically changed by the approval of tyrosine kinase inhibitors (TKIs), which target BCR-ABL1 kinase activity. CML is now managed as a chronic disease requiring long-term treatment and close molecular monitoring. It has been shown that in a substantial number of patients who have achieved a stable deep molecular response (DMR), TKI treatment can be safely discontinued without loss of response. Therefore, treatment-free remission (TFR), through the achievement of a DMR, is increasingly regarded as a feasible treatment goal in many CML patients. However, only nilotinib has approval in this setting and a number of controversial aspects remain regarding treatment choices and timings, predictive factors, patient communication, and optimal strategies to achieve successful TFR. This narrative review aims to provide a comprehensive overview on how to optimize the path to DMR and TFR in patients with CML, and discusses recent data and future directions.
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Affiliation(s)
| | | | - Massimo Breccia
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Fausto Castagnetti
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. and A. Seràgnoli”, “S. Orsola-Malpighi” Univeristy Hospital, University of Bologna, Bologna, Italy
| | - Antonella Gozzini
- Department of Cellular Therapy and Transfusional Medicine, AUO Careggi, Florence, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Pregno
- Hematology Division, Oncology and Hematology Department, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fabio Stagno
- Division of Hematology and Bone Marrow Transplant, AOU Policlinico—V. Emanuele, Catania, Italy
| | - Giorgina Specchia
- Hematology Section, Department of Emergency and Organ Transplantation, University of Bari-Aldo Moro, Bari, Italy
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26
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Yamazaki K, Inagaki N, Moldaver D, Viana R, Kimura S. Budget impact analysis of treatment-free remission in nilotinib-treated Japanese chronic myeloid leukemia patients. Cancer Sci 2020; 111:2526-2535. [PMID: 32324296 PMCID: PMC7385357 DOI: 10.1111/cas.14430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 01/05/2023] Open
Abstract
Treatment‐free remission (TFR), in which patients discontinue pharmacotherapy and remain in molecular remission, is an emerging treatment goal for patients with chronic myeloid leukemia (CML). Attainment of TFR requires an increased frequency of molecular monitoring, to ensure that patients maintain a deep molecular response. The objective of this analysis was to assess the economic impact of stopping nilotinib among Japanese TFR‐eligible patients. A Markov model evaluated the economic impact of TFR among the study population, TFR‐eligible CML patients diagnosed since 2012. The model compared patients who had discontinued tyrosine kinase inhibitor (TKI) treatment (ie, attempted TFR) with patients that continued TKI treatment. A 3‐y time horizon was modeled from a Japanese public payer perspective. Costs associated with drug treatment, hospital/physician visits, and molecular monitoring were considered. TFR‐eligible patients were calculated from Japanese CML incidence rates and efficacy was derived from nilotinib trials. Japanese co‐payment maximums were utilized to assess the patient perspective. An estimated 761 and 140 patients were eligible for first‐ and second‐line nilotinib, respectively, in 2019. Assuming that 100% of eligible patients complied, TFR was associated with cost savings of ¥7 625 174 640 (US$66 567 775) over 3 y. In scenarios with reduced willingness to attempt TFR, cost savings persisted. Achievement of TFR was estimated to markedly reduce out‐of‐pocket expenses for CML patients, regardless of the timing of relapse. Stopping nilotinib for TFR‐eligible patients in Japan may result in significant cost savings to both payers and patients. Monitoring costs contributed little to overall annual costs and decreased over time.
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Affiliation(s)
| | | | | | | | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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27
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Nishiwaki K, Sugimoto KJ, Tamaki S, Hisatake J, Yokoyama H, Igarashi T, Shinagawa A, Sugawara T, Hara S, Fujikawa K, Shimizu S, Yujiri T, Tojo A, Wakita H. Optimal treatment strategy with nilotinib for patients with newly diagnosed chronic-phase chronic myeloid leukemia based on early achievement of deep molecular response (MR 4.5 ): The phase 2, multicenter N-Road study. Cancer Med 2020; 9:3742-3751. [PMID: 32253827 PMCID: PMC7286457 DOI: 10.1002/cam4.3034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 03/04/2020] [Accepted: 03/15/2020] [Indexed: 01/06/2023] Open
Abstract
For patients who have chronic myeloid leukemia (CML), one of the primary treatment options is administration of nilotinib 300 mg twice daily (BID). In previous studies which compared outcomes associated with nilotinib or imatinib treatment, nilotinib achieved a higher rate of deep molecular response (MR). We conducted a phase II, open‐label, multicenter study to investigate an intrapatient nilotinib dose‐escalation strategy for patients with newly diagnosed chronic‐phase (CP) CML based on early MR4.5 achievement. The primary study endpoint was achievement of MR4.5 by 24 months following the initiation of nilotinib 300 mg BID. Fifty‐three patients were enrolled, 51 received nilotinib, and 37 completed the treatment. An increase in the nilotinib dose (to 400 mg BID) was allowed when patients satisfied our criteria for no optimal response at any time point. The median (range) dose intensity was 600 (207‐736) mg/day. Of 46 evaluable patients, 18 achieved an optimal response and 28 did not. Of the latter, nine patients underwent dose escalation to 400 mg BID, and none achieved MR4.5. The remaining 19 patients could not undergo dose escalation, 12 (63%) because of adverse events (AEs), and 7 (37%) for non‐AE related reasons. Four of these patients achieved MR4.5. The MR4.5 rate by 24 months was 45.7%. The progression‐free, overall and event‐free survival were each 97.6%. No new safety concerns were observed. Our findings support the use of continuous nilotinib at a dose of 300 mg BID for newly diagnosed patients with CML‐CP.
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Affiliation(s)
- Kaichi Nishiwaki
- Division of Oncology and Hematology, Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Kei-Ji Sugimoto
- Division of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Shigehisa Tamaki
- Department of Hematology/Infectious Disease, Ise Red Cross Hospital, Ise, Japan
| | - Junichi Hisatake
- Department of Hematology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hisayuki Yokoyama
- Department of Hematology, National Hospital Organization, Sendai Medical Center, Sendai, Japan
| | - Tadahiko Igarashi
- Division of Hematology and Oncology, Gunma Cancer Center, Ohta, Japan
| | - Atsushi Shinagawa
- Department of Internal Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Takeaki Sugawara
- Division of Hematology-Oncology, Chiba Cancer Center, Chiba, Japan
| | - Satoru Hara
- Department of Hematology, Chiba Rosai Hospital, Chiba, Japan
| | - Kazuhisa Fujikawa
- Department of Hematology, Chibaken Saiseikai Narashino Hospital, Narashino, Japan
| | - Seiichi Shimizu
- Department of Hematology, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Toshiaki Yujiri
- Third Department of Internal Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Arinobu Tojo
- Division of Molecular Therapy, Institute of Medical Science, Tokyo University, Tokyo, Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Society, Narita Red Cross Hospital, Narita, Japan
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28
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Hochhaus A, Baccarani M, Silver RT, Schiffer C, Apperley JF, Cervantes F, Clark RE, Cortes JE, Deininger MW, Guilhot F, Hjorth-Hansen H, Hughes TP, Janssen JJWM, Kantarjian HM, Kim DW, Larson RA, Lipton JH, Mahon FX, Mayer J, Nicolini F, Niederwieser D, Pane F, Radich JP, Rea D, Richter J, Rosti G, Rousselot P, Saglio G, Saußele S, Soverini S, Steegmann JL, Turkina A, Zaritskey A, Hehlmann R. European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia. Leukemia 2020; 34:966-984. [PMID: 32127639 PMCID: PMC7214240 DOI: 10.1038/s41375-020-0776-2] [Citation(s) in RCA: 770] [Impact Index Per Article: 192.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
The therapeutic landscape of chronic myeloid leukemia (CML) has profoundly changed over the past 7 years. Most patients with chronic phase (CP) now have a normal life expectancy. Another goal is achieving a stable deep molecular response (DMR) and discontinuing medication for treatment-free remission (TFR). The European LeukemiaNet convened an expert panel to critically evaluate and update the evidence to achieve these goals since its previous recommendations. First-line treatment is a tyrosine kinase inhibitor (TKI; imatinib brand or generic, dasatinib, nilotinib, and bosutinib are available first-line). Generic imatinib is the cost-effective initial treatment in CP. Various contraindications and side-effects of all TKIs should be considered. Patient risk status at diagnosis should be assessed with the new EUTOS long-term survival (ELTS)-score. Monitoring of response should be done by quantitative polymerase chain reaction whenever possible. A change of treatment is recommended when intolerance cannot be ameliorated or when molecular milestones are not reached. Greater than 10% BCR-ABL1 at 3 months indicates treatment failure when confirmed. Allogeneic transplantation continues to be a therapeutic option particularly for advanced phase CML. TKI treatment should be withheld during pregnancy. Treatment discontinuation may be considered in patients with durable DMR with the goal of achieving TFR.
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MESH Headings
- Aniline Compounds/therapeutic use
- Antineoplastic Agents/therapeutic use
- Clinical Decision-Making
- Consensus Development Conferences as Topic
- Dasatinib/therapeutic use
- Disease Management
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Gene Expression
- Humans
- Imatinib Mesylate/therapeutic use
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Life Expectancy/trends
- Monitoring, Physiologic
- Nitriles/therapeutic use
- Protein Kinase Inhibitors/therapeutic use
- Pyrimidines/therapeutic use
- Quality of Life
- Quinolines/therapeutic use
- Survival Analysis
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Affiliation(s)
- A Hochhaus
- Klinik für Innere Medizin II, Universitätsklinikum, Jena, Germany.
| | - M Baccarani
- Department of Hematology/Oncology, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - R T Silver
- Weill Cornell Medical College, New York, NY, USA
| | - C Schiffer
- Karmanos Cancer Center, Detroit, MI, USA
| | - J F Apperley
- Hammersmith Hospital, Imperial College, London, UK
| | | | - R E Clark
- Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - J E Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - M W Deininger
- Huntsman Cancer Center Salt Lake City, Salt Lake City, UT, USA
| | - F Guilhot
- Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - H Hjorth-Hansen
- Norwegian University of Science and Technology, Trondheim, Norway
| | - T P Hughes
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - J J W M Janssen
- Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands
| | | | - D W Kim
- St. Mary´s Hematology Hospital, The Catholic University, Seoul, Korea
| | | | | | - F X Mahon
- Institut Bergonie, Université de Bordeaux, Bordeaux, France
| | - J Mayer
- Department of Internal Medicine, Masaryk University Hospital, Brno, Czech Republic
| | | | | | - F Pane
- Department Clinical Medicine and Surgery, University Federico Secondo, Naples, Italy
| | - J P Radich
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - D Rea
- Hôpital St. Louis, Paris, France
| | | | - G Rosti
- Department of Hematology/Oncology, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - P Rousselot
- Centre Hospitalier de Versailles, University of Versailles Saint-Quentin-en-Yvelines, Versailles, France
| | - G Saglio
- University of Turin, Turin, Italy
| | - S Saußele
- III. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - S Soverini
- Department of Hematology/Oncology, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | | | - A Turkina
- National Research Center for Hematology, Moscow, Russian Federation
| | - A Zaritskey
- Almazov National Research Centre, St. Petersburg, Russian Federation
| | - R Hehlmann
- III. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany.
- ELN Foundation, Weinheim, Germany.
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29
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Franke GN, Maier J, Wildenberger K, Cross M, Giles FJ, Müller MC, Hochhaus A, Niederwieser D, Lange T. Comparison of Real-Time Quantitative PCR and Digital Droplet PCR for BCR-ABL1 Monitoring in Patients with Chronic Myeloid Leukemia. J Mol Diagn 2020; 22:81-89. [DOI: 10.1016/j.jmoldx.2019.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/18/2019] [Accepted: 08/28/2019] [Indexed: 10/25/2022] Open
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30
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Zhang JW, Fu Y, Wu QS, Bao LH, Peng RX, Zhang R, Li JM. Standardization of BCR-ABL1 quantification on the international scale in China using locally developed secondary reference panels. Exp Hematol 2019; 81:42-49.e3. [PMID: 31863797 DOI: 10.1016/j.exphem.2019.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 01/31/2023]
Abstract
For patients with chronic myeloid leukemia, reverse transcription quantitative polymerase chain reaction is widely used in laboratories to quantify BCR-ABL1 fusion gene transcripts for disease management. Many efforts have been made to standardize the BCR-ABL1 testing assay, including the primary and secondary reference reagents, but the secondary standards have not been developed and used in the standardization program in China. With the use of armored RNA technology, armored RNA of BCR-ABL1 and control genes was manufactured to prepare the secondary reference material anchored to the World Health Organization primary reference calibrators for standardization of BCR-ABL1 testing assays. The secondary reference was sent to 30 laboratories in China for validation. Data from an external quality assessment after the standardization process were collected and analyzed as well. The assigned %BCR-ABL1/ABL1IS values of the four levels of the secondary material panels were 0.0118, 0.1345, 1.3808, and 19.4266, respectively. In validation trials, 70.0% (21/30) of laboratories obtained valid conversion factors for the BCR-ABL1 assay. All valid conversion factors from 11 international scale laboratories were equivalent to their respective previous values. External quality assessment data indicated that the accuracy and precision between laboratories were improved. Moreover, the quantity of the panels is abundant to be used as quality control samples for monitoring the shift of data. In this study, we established a secondary genetic reference panel for BCR-ABL1 quantification. This study will play a role in facilitating the worldwide dissemination of the international scale, especially in promoting the standardization of molecular monitoring in China.
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Affiliation(s)
- Jia-Wei Zhang
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China
| | - Yu Fu
- Department of Nuclear Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Qi-Sheng Wu
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China
| | - Li-Hua Bao
- Department of Nuclear Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Rong-Xue Peng
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China
| | - Rui Zhang
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China; Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China.
| | - Jin-Ming Li
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, People's Republic of China.
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Abstract
PURPOSE OF REVIEW The marked improvement in clinical outcomes for patients with chronic myeloid leukaemia (CML) can be solely attributed to the introduction of targeted therapies against the fusion oncoprotein, BCR-ABL1. However, patient responses, although generally positive, remain heterogenous. Careful drug selection, ensuring the optimal TKI, is chosen for each patient and involves a complex decision process which incorporates consideration of numerous factors. RECENT FINDINGS For some patients, with disease characteristics that indicate adverse intrinsic disease biology, more potent BCR-ABL1 inhibition is often appropriate, whereas other patients with major co-morbidities will benefit from a less aggressive approach to avoid life-shortening toxicities. For the vast majority of patients, the long-term goal of therapy will be the achievement of a deep molecular response and subsequent treatment-free remission and this consideration will play a large part in the drug selection process. We explore early management of CML, from the first presentation through to frontline therapy selection.
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Berdeja JG, Heinrich MC, Dakhil SR, Goldberg SL, Wadleigh M, Kuriakose P, Cortes J, Radich J, Helton B, Rizzieri D, Paley C, Dautaj I, Mauro MJ. Rates of deep molecular response by digital and conventional PCR with frontline nilotinib in newly diagnosed chronic myeloid leukemia: a landmark analysis. Leuk Lymphoma 2019; 60:2384-2393. [PMID: 30912699 DOI: 10.1080/10428194.2019.1590569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 02/08/2019] [Accepted: 02/25/2019] [Indexed: 02/04/2023]
Abstract
ENESTnext (NCT01227577) was a single-arm, multicenter trial evaluating the rate of deep molecular response by 2 years in patients with newly diagnosed (within 6 months) chronic myeloid leukemia in chronic phase (CML-CP) treated with nilotinib 300 mg twice daily. Among 128 enrolled patients, 94 (73%) achieved major molecular response (MMR; BCR-ABL1 ≤ 0.1% on the International Scale [BCR-ABL1IS]) and 34 (27%) achieved confirmed MR4.5 (BCR-ABL1IS ≤0.0032% detectable or undetectable; primary endpoint) by 2 years. Three-month BCR-ABL1 levels were predictive of later responses. In exploratory analyses, digital polymerase chain reaction (PCR) detected BCR-ABL1 in 39.4% of samples from patients with confirmed MR4.5 and identified further decreases in BCR-ABL1 with continued nilotinib. Safety results, including cardiovascular events, were consistent with those in other nilotinib trials. These results further substantiate the molecular response rates associated with frontline nilotinib therapy and demonstrate the feasibility of monitoring very low BCR-ABL1 transcript levels using digital PCR.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Clinical Trials, Phase IV as Topic
- Female
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Molecular Targeted Therapy
- Multicenter Studies as Topic
- Polymerase Chain Reaction
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/therapeutic use
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/therapeutic use
- Real-Time Polymerase Chain Reaction
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
| | - Michael C Heinrich
- VA Portland Health Care System, Oregon Health & Science University Knight Cancer Institute , Portland , OR , USA
| | | | - Stuart L Goldberg
- John Theurer Cancer Center, Hackensack University Medical Center , Hackensack , NJ , USA
| | | | | | - Jorge Cortes
- MD Anderson Cancer Center, The University of Texas , Houston , TX , USA
| | - Jerald Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Bret Helton
- Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | | | - Carole Paley
- Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - Ilva Dautaj
- Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - Michael J Mauro
- Memorial Sloan Kettering Cancer Center , New York , NY , USA
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33
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Xu H, Wang P, Ma RJ, Guo JM, Lei PC, Zang YZ, Wang TB, Liu ZW, Yang J, Zhang Y, Zhu ZM. [Comparative study of molecular response of first-line and second-line nilotinib in patients with chronic-phase chronic myelogenous leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:522-525. [PMID: 31340628 PMCID: PMC7342397 DOI: 10.3760/cma.j.issn.0253-2727.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- H Xu
- Jinzhou Medical University, Jinzhou 121001, China; Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - P Wang
- Hematology of Department, Xinyang Central Hospital, Xinyang 464000, China
| | - R J Ma
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - J M Guo
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - P C Lei
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Y Z Zang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - T B Wang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Z W Liu
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - J Yang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Y Zhang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Z M Zhu
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China; Institute of Hematology, Henan Province People's Hospital, Zhengzhou 450003, China
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Huguet F, Cayuela J, Cambier N, Carpentier N, Tindel M, Violet I, Zunic P, Lascaux A, Etienne G, Didier Innocent ADIKO, Shanti AMENATARAJAN, Carla ARAUJO, Omar BENBRAHIM, Martial BOISSEAU, Dominique BORDESSOULE, Azzedine BOUDERBALA, Nathalie CAMBIER, Valerie COITEUX, Pascale CONYMAKHOUL, Regis COSTELLO, Martine DELAIN, Viviane DUBRUILLE, Abderrazak ELYAMANI, Gabriel ETIENNE, Jose FERNANDES, Reda GARIDI, Agnes GUERCIBRESLER, Denis GUYOTAT, Maya HACINI, Eric HERMET, Francoise HUGUET, Jean Christophe IANOTTO, Bertrand JOLY, Eric JOURDAN, Fabrice LAROSA, Axelle LASCAUX, Sophie LEFORT, Anne MARFAING, Jean-Pierre MAROLLEAU, Jessica MICHEL, Franck NICOLINI, Isabelle PLANTIER, Philippe QUITTET, Philippe RODON, Laurence SANHES, Ioana VAIDA, Bruno VILLEMAGNE, Sorin VISANICA, Laurent VOILLAT, Patricia ZUNIC. Nilotinib efficacy, safety, adherence and impact on quality of life in newly diagnosed patients with chronic myeloid leukaemia in chronic phase: a prospective observational study in daily clinical practice. Br J Haematol 2019; 187:615-626. [DOI: 10.1111/bjh.16145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/05/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Françoise Huguet
- Department of Haematology Toulouse University Cancer Institute ToulouseFrance
| | - Jean‐Michel Cayuela
- Laboratory of Haematology University Hospital Saint‐Louis AP‐HP and EA3518, University Paris Diderot ParisFrance
| | - Nathalie Cambier
- Department of Oncology and Haematology Saint Vincent de Paul Hospital LilleFrance
| | | | | | | | - Patricia Zunic
- Department of Haematology University Hospital Centre, Saint‐Pierre Reunion IslandFrance
| | - Axelle Lascaux
- Department of Clinical Haematology and Cell Therapy Haut‐Lévêque Hospital, Bordeaux University Hospital PessacFrance
| | - Gabriel Etienne
- Department of Medical Oncology Institut Bergonié Bordeaux France
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35
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Massimino M, Stella S, Tirrò E, Consoli ML, Pennisi MS, Puma A, Vitale SR, Romano C, Zammit V, Stagno F, Di Raimondo F, Manzella L. Rapid decline of Philadelphia-positive metaphases after nilotinib treatment in a CML patient expressing a rare e14a3 BCR-ABL1 fusion transcript: A case report. Oncol Lett 2019; 18:2648-2653. [PMID: 31404304 DOI: 10.3892/ol.2019.10558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022] Open
Abstract
We report a case of chronic myeloid leukemia in a 52-year-old male expressing a rare e14a3 BCR-ABL1 fusion transcript. Cytogenetic analysis showed the t(9;22) translocation and multiplex RT-PCR detected an atypical fragment of approximately 230 base pairs. Using two primers recognizing exon 10 of BCR and exon 4 of ABL1, a larger PCR product was identified, cloned, sequenced and defined as an e14a3 BCR-ABL1 rearrangement. The patient was treated with nilotinib and monitored measuring cytogenetic and hematological parameters, while BCR-ABL1 transcripts were surveyed by conventional and semi-nested PCR. The patient achieved a complete hematologic response after two months of treatment followed by a complete cytogenetic remission two months later. Furthermore, PCR and semi-nested PCR failed to detect the e14a3 BCR-ABL1 mRNA after 15 and 21 months of nilotinib, respectively.
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Affiliation(s)
- Michele Massimino
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Stefania Stella
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Elena Tirrò
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Maria Letizia Consoli
- Division of Hematology and Bone Marrow Transplant, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Maria Stella Pennisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Adriana Puma
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Silvia Rita Vitale
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Chiara Romano
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Valentina Zammit
- Division of Hematology and Bone Marrow Transplant, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Fabio Stagno
- Division of Hematology and Bone Marrow Transplant, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
| | - Francesco Di Raimondo
- Division of Hematology and Bone Marrow Transplant, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy.,Department of Surgery, Medical and Surgical Specialties, University of Catania, Catania I-95123, Italy
| | - Livia Manzella
- Department of Clinical and Experimental Medicine, University of Catania, Catania I-95123, Italy.,Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania I-95123, Italy
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36
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Role of Cancer-Associated Fibroblast in Gastric Cancer Progression and Resistance to Treatments. JOURNAL OF ONCOLOGY 2019; 2019:6270784. [PMID: 31281359 PMCID: PMC6590541 DOI: 10.1155/2019/6270784] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/23/2019] [Indexed: 12/21/2022]
Abstract
Although the survival of gastric cancer (GC) patients has gradually improved, the outcomes of advanced GC patients remain unsatisfactory despite standard treatment with conventional chemotherapy or targeted agents. Several studies have shown that cancer-associated fibroblasts (CAFs), a major component of tumor stroma in GC, may have significant roles in GC progression and resistance to treatments. CAFs are a major source of various secreted molecules in the tumor microenvironment, which stimulate cancer cells and other noncancerous components of GC. Surprisingly, these factors could be involved in gastric carcinogenesis. Cytokines, including interleukin-6 and interleukin-11, or growth factors, such as fibroblast growth factor produced from CAFs, can directly activate GC cells and consequently lead to the development of an aggressive phenotype. Galectin-1 or hepatocyte growth factor can be involved in CAF-derived neovascularization in GC. In addition, recent studies showed that CAFs can affect tumor immunity through M2 polarization of tumor-associated macrophages. Finally, the current study aimed to introduce several inhibitory agents and evaluate their suppressive effects on CAFs in patients with GC progression. However, further studies are required to evaluate their safety and select appropriate patients for application in clinical settings.
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37
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Wang R, Cong Y, Li C, Zhang C, Lin H. Predictive value of early molecular response for deep molecular response in chronic phase of chronic myeloid leukemia. Medicine (Baltimore) 2019; 98:e15222. [PMID: 30985724 PMCID: PMC6485861 DOI: 10.1097/md.0000000000015222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the association of 3- and 6-month BCR-ABL transcript levels on the international scale (BCR-ABL) and other factors with deep molecular response (DMR) achievement in chronic myeloid leukemia (CML)-chronic phase (CP) patients receiving tyrosine kinase inhibitor (TKI) therapy.We retrospectively analyzed the clinical data of 206 patients enrolled in our hospital between January 2010 and July 2018. These patients were initially diagnosed with CML-CP and received imatinib or nilotinib therapy. Early molecular response (EMR) was assessed based on BCR-ABL (IS: on the international scale) transcript level at 3 and 6 months. Potential factors impacting DMR achievement were identified using Cox proportional hazard regression models. The effects of EMR achievement on the cumulative incidence of MR4.0 were investigated via Kaplan-Meier analysis.Multivariate Cox regression analysis showed that a BCR-ABL transcript level at 3 and 6 months of TKI therapy was an independent factor for the achievement of MR4.0, which was nevertheless not related to age, gender, Sokal score, hemoglobin level, or white blood cell (WBC) count at the initial time of diagnosis. Patients achieving an EMR (EMR: 3-month BCR-ABL ≤10%, 6-month BCR-ABL <1%) were more likely to reach MR4.0 than patients failing to achieve EMR (P1 <.001, P2 <.001). Patients who had 3-month BCR-ABL ≤1% were more likely to reach MR4.0 than those who had 3-month BCR-ABL of 1% to 10% or >10% (P1 = .001, P2 <.001). Similarly, patients who had 6-month BCR-ABL ≤0.1% were more likely to achieve MR4.0 than those in the 0.1% to 1% and ≥1% groups (P1 <.001, P2 <.001). Also, a higher percentage of patients on nilotinib therapy achieved EMR compared with patients on imatinib therapy (93.3% vs 63.6% on 3-month nilotinib therapy, P = .001; 88.9% vs 59.9% on 6-month nilotinib therapy, P = .004).This study demonstrates that EMR, especially a 3-month BCR-ABL ≤1% and 6-month BCR-ABL ≤0.1%, have predictive value for DMR achievement. In addition, there is a higher percentage of patients receiving nilotinib therapy achieved EMR than that of those receiving imatinib therapy.
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Affiliation(s)
- Rui Wang
- Department of Hematology, The First Hospital of Jilin University
| | - Yue Cong
- Department of Ocular Fundus Disease, The Second Hospital of Jilin University, Changchun
| | - Caili Li
- Department of Hematology, Yantai Yuhuangding Hospital, Yantai, China
| | - Chen Zhang
- Department of Hematology, The First Hospital of Jilin University
| | - Hai Lin
- Department of Hematology, The First Hospital of Jilin University
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38
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Borghi L, Galimberti S, Baratè C, Bonifacio M, Capochiani E, Cuneo A, Falzetti F, Iurlo A, Lunghi F, Minotto C, Orlandi EM, Rege-Cambrin G, Sica S, Supekar S, Haenig J, Vegni E. Chronic Myeloid Leukemia Patient's Voice About the Experience of Treatment-Free Remission Failure: Results From the Italian Sub-Study of ENESTPath Exploring the Emotional Experience of Patients During Different Phases of a Clinical Trial. Front Psychol 2019; 10:329. [PMID: 30842749 PMCID: PMC6391340 DOI: 10.3389/fpsyg.2019.00329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 02/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background: The main objective of this study is to gain further insights on how chronic myeloid leukemia (CML) patients involved in an interventional clinical trial with the purpose of reaching treatment free remission (TFR) phase, perceived and experienced TFR failure. TFR failure was defined for the individual patient as either not being eligible for drug discontinuation or as having relapse in the TFR phase with reintroduction of nilotinib treatment. Methods: Using a qualitative approach, out of 25 patients with CML who experienced TFR failure 14 were interviewed. Patients' views and experiences were explored using in-depth interviews, analyzed using the Interpretative Phenomenological Analysis (IPA). Results: The analysis of the interviews revealed that the experience of the diagnosis seems to have been lived as a traumatic break that has created a dichotomy, like an ambivalence in the ways in which CML patients perceived and experienced the whole disease journey, with contradictory feelings of both positive and negative emotions (e.g., a diagnosis of cancer, that is something distressing and of being afraid of, but also with a treatment and a life expectancies of which being grateful). This ambivalence of feelings was found to give meaning to the way in which patients cognitively and emotionally experienced the different steps of their disease history. Thus, four main issues, corresponding to different steps of the patients' journey, were identified: (1) the moment of the diagnosis, (2) the experience of the illness journey: disease and treatment, (3) the moment of "TFR failure," and (4) the impact of disease, treatment and relapse on the patient's life. Conclusion: This qualitative analysis helps in understanding patients' perspective, both in terms of getting access to the inner subjective experience of having CML and its strict relationship with the involvement in a trial or its cessation. Clinicians should consider that the way in which CML patients feel engaged in a clinical trial, create expectancies about TFR or experience the TFR failure is linked to the process of coping with the diagnosis, which is characterized by ambivalence.
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Affiliation(s)
- Lidia Borghi
- Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | | | | | - Antonio Cuneo
- Institute of Hematology, University of Ferrara, Ferrara, Italy
| | - Franca Falzetti
- Institute of Hematology, Centro di Ricerca Emato-Oncologico (CREO), University of Perugia, Perugia, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Minotto
- UOS Hematology, UOC Oncologiaed Ematologia Oncologica AULSS3, Mestre, Italy
| | | | - Giovanna Rege-Cambrin
- Division of Hematology and Internal Medicine, “San Luigi Gonzaga” University Hospital, Orbassano, University of Turin, Turin, Italy
| | - Simona Sica
- Fondazione Policlinico Universitario Agostino Gemelli – IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sharon Supekar
- Oncology Region Europe, Novartis Farma SpA, Origgio, Italy
| | - Jens Haenig
- Oncology Region Europe, Novartis Farma SpA, Origgio, Italy
| | - Elena Vegni
- Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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39
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Abstract
With an annual incidence of 1–2 in a million, Ph*(+) chronic myeloid leukemia (CML) is a clonal hematopoietic stem cell disease that makes myeloid neoplastic cells breed out of control. This BCR-ABL(+) myeloproliferative disease makes up about 15%–20% of all leukemia cases in adults. CML is seen more in males than females, with a rate of three to two. However, it does not show differences in prevalence in terms of age. CML consists of three clinical phases. The first one is the chronic phase, defined by rising white blood cell levels and also by myeloid proliferation and bone marrow maturation. While this phase does not exhibit complications, in diagnosis, it comprises most of the patients. The second phase is the accelerated phase, which the disease progresses to if it is not treated or does not respond to treatment. This usually takes about 3 years. The third phase is the blastic phase. The chronic phase can still progress to the next two phases within the first 2 years, with a rate of 10%. In the following years, the possibility increases by 15%–20% each year. Tyrosine kinase inhibitors (TKIs) are revolutionary drugs for the management of disease course in CML. The aim of this review is to assess current approaches to CML patients’ follow-up and treatment with TKIs. A literature search on CML and TKIs was made in PubMed, Web of Science, and Scopus with particular focus on randomized clinical trials, recommendations, guidelines, and expert opinions. In managing CML, various treatment methods have been utilized for many decades. Prior to the development of TKIs, interferon alpha was the primary tool, which was then complemented by allogeneic hematopoietic stem cell transplantation (HSCT). HSCT was successful in slowing the disease down in the long term and curing up to 50% of patients. Then the coming of the imatinib era opened up different treatment perspectives. For the patients resistant or intolerant to imatinib, second- and third-generation TKIs are successfully used in distinct CML disease states. The survival benefits of TKIs including imatinib, nilotinib, dasatinib, bosutinib, and ponatinib for CML patients are outstanding. TKI-related adverse events could impact the clinical course, especially in long-term drug administrations. The current aim for CML disease management in the TKI era is to provide age- and sex-matched normal life duration to CML patients.
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Affiliation(s)
- Elifcan ALADAĞ
- Department of Hematology, Faculty of Medicine, Hacettepe University, AnkaraTurkey
- * To whom correspondence should be addressed. E-mail:
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40
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Tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia: a single-institution experience. J Hematol Oncol 2019; 12:1. [PMID: 30606227 PMCID: PMC6318861 DOI: 10.1186/s13045-018-0686-1] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/10/2018] [Indexed: 12/16/2022] Open
Abstract
Background Patients with CML treated with TKI can have a life expectancy comparable to that of the general population. Due to the extended duration of TKI administration, treatment discontinuation has been increasingly sought. Methods Medical records of 100 patients with CML who were in MR4.5 and discontinued their TKI outside clinical trials were reviewed. Results After a median follow-up of 30 months (range, 5–112 months) after discontinuation, 35% and 17% lost MR4.5 and major molecular response (MMR), respectively. Only six patients lost MMR 12 months or more after discontinuation. Loss of MR4.5 was observed in 29% and 7% of patients with sustained MR4.5 duration of more than 2 and 6 years before discontinuation, respectively. By univariate analysis, there was a higher risk of loss of MR4.5 for patients who were treated for less than 87 months, received second or subsequent line TKI, never received interferon, or those with sustained MR4.5 for less than 6 years. By multivariate analysis, sustained MR4.5 for 6 years or more was the only significant predictor for durable response. Overall, 30% of patients who discontinued while in MR4.5 were retreated with 93% regaining MR4.5 at a median of 5 months. Conclusion These results demonstrate that under proper conditions, treatment discontinuation is feasible outside of clinical trial setting. MR4.5 duration of 6 years or more before discontinuation is associated with very low risk of loss of MR4.5.
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41
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Claudiani S, Apperley JF. The argument for using imatinib in CML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:161-167. [PMID: 30504305 PMCID: PMC6246007 DOI: 10.1182/asheducation-2018.1.161] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
June 2018 was the 20th anniversary of the clinical use of the first tyrosine kinase inhibitor (TKI), imatinib, for chronic myeloid leukemia. Since then, the change in prognosis for patients with this disease is one of the major success stories of modern cancer medicine. The dilemmas that face physicians and patients are no longer only those concerned with delaying inevitable progression to the terminal blastic phase or selecting the individuals most likely to benefit from allogeneic stem-cell transplantation; rather, they are now focused also on the choice of TKI, the management of comorbidities and adverse effects, strategies to improve quality of life, and the appropriateness of a trial of therapy discontinuation. Interestingly, with 4 TKIs approved for frontline use, the choice of initial therapy continues to cause controversy, a situation made more complicated by the tantalizing prospect of treatment-free remission. In this manuscript, we will explore the factors influencing this decision and try to provide a pragmatic and clinically applicable solution.
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Affiliation(s)
- Simone Claudiani
- Department of Clinical Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Jane F. Apperley
- Department of Clinical Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
- Centre for Haematology, Imperial College London, London, United Kingdom
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Fu Y, Zhang R, Wu Q, Zhang J, Bao L, Li J. External quality assessment of p210 BCR-ABL1 transcript quantification by RT-qPCR: Findings and recommendations. Int J Lab Hematol 2018; 41:46-54. [PMID: 30203581 DOI: 10.1111/ijlh.12919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION External quality assessment (EQA) is an essential tool for quality assurance of analytical testing processes of p210 BCR-ABL1 transcripts by RT-qPCR. As an EQA provider, the National Center for Clinical Laboratories organized an EQA scheme of p210 BCR-ABL1 testing in China for the first time to identify existing problems and ensure the reliability of p210 BCR-ABL1 testing. METHODS Using armored RNA technology, we first constructed pACYC-MS2-p210 and CG recombinant plasmids and expressed p210 and CG armored RNAs, with packaging segments of p210 BCR-ABL1 fusion gene (FG) and four common control gene (CG) transcripts. Using these armored RNAs, we prepared lyophilized p210 quality control (QC) sample panels and evaluated detection performance of participating laboratories in China. RESULTS Of the 66 participating laboratories, great variation was found with coefficient of variation (CV%) of raw p210 BCR-ABL1 results basically ranging from 60.0% to 100.0%. In 24 International Scale (IS) laboratories, the CV% of results decreased from 82.4% to 61.6%, and the percentage of laboratories within 2-, 3-, and 5-fold of the median values increased from 78.2%, 87.0%, and 92.1% to 80.1%, 89.4%, and 97.2%, respectively, after conversion with a laboratory-specific conversion factor (CF); however, poorly converted results were also observed in laboratories resulting from changed components of RT-qPCR procedures. False-negative and false-positive results were also found in the EQA. CONCLUSIONS Various problems were found for p210 BCR-ABL1 detection in the EQA. By solving the existing problems, the performance of p210 BCR-ABL1 detection can be improved, ensuring robust laboratory diagnostic capacities in China.
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Affiliation(s)
- Yu Fu
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Rui Zhang
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Qisheng Wu
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Jiawei Zhang
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Lihua Bao
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinming Li
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
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43
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Saydam G, Haznedaroglu IC, Kaynar L, Yavuz AS, Ali R, Guvenc B, Akay OM, Baslar Z, Ozbek U, Sonmez M, Aydin D, Pehlivan M, Undar B, Dagdas S, Ayyildiz O, Akin G, Dag IM, Ilhan O. Frontline nilotinib treatment in Turkish patients with Philadelphia chromosome-positive chronic Myeloid Leukemia in chronic phase: updated results with 2 years of follow-up. ACTA ACUST UNITED AC 2018; 23:771-777. [PMID: 29996726 DOI: 10.1080/10245332.2018.1498167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This report presents final results (24 months of follow-up) from the first prospective, national study of frontline nilotinib in chronic myeloid leukemia (CML) patients in Turkey. METHODS Patients with newly diagnosed Philadelphia chromosome-positive CML in chronic phase (CML-CP; N = 112) received nilotinib 300 mg twice daily. The primary endpoint, which was the cumulative rate of major molecular response (MMR; BCR-ABL1 ≤ 0.1% on the International Scale [BCR-ABL1IS]) by 12 months, was previously reported (66.1% [80% CI, 59.7%-72.0%]). ClinicalTrials.gov identifier NCT01274351 Results: By 24 months, 83.0% of patients achieved MMR, and 50.9% achieved MR4.5 (BCR-ABL1IS ≤0.0032%). Safety results at 24 months were consistent with those at 12 months. No additional deaths or disease progressions to accelerated phase/blast crisis were observed between 12 and 24 months. DISCUSSION Treatment with nilotinib 300 mg twice daily for 2 years provided high MMR with a good safety/tolerability profile in newly diagnosed CML-CP patients in Turkey. Assessment of MMR across time points showed increasing rates through 18 months, after which as lower rate of increase was observed. The safety profile of nilotinib 300 mg twice daily with 24 months of follow-up was similar to that observed at 12 months, and no new safety concerns were identified. These efficacy and safety findings are consistent with the results from the 12-month analysis of this study and from previous nilotinib studies. These findings support nilotinib as an option for frontline treatment of CML-CP. CONCLUSION Frontline nilotinib treatment provided sustained efficacy, with good tolerability, over 24 months in newly diagnosed CML-CP patients.
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Affiliation(s)
- Guray Saydam
- a Ege University Medical Faculty Hospital , Department of Internal Medicine , Izmir , Turkey
| | | | - Leylagul Kaynar
- c Erciyes University Medical Faculty Hospital , Hematology Division , Kayseri , Turkey
| | - Akif S Yavuz
- d Istanbul University , Istanbul Medical Faculty, Department of Internal Medicine , Istanbul , Turkey
| | - Ridvan Ali
- e Uludag University Medical Faculty , Department of Internal Medicine , Bursa , Turkey
| | - Birol Guvenc
- f Cukurova University Medical Faculty Hospital , Department of Internal Medicine , Adana , Turkey
| | - Olga M Akay
- g Eskisehir Osmangazi Unıversity Medical Faculty Hospital , Department of Internal Medicine , Eskisehir , Turkey
| | - Zafer Baslar
- h Istanbul University Cerrahpasa Medical Faculty , Department of Internal Medicine , Istanbul , Turkey
| | - Ugur Ozbek
- i Acibadem University Faculty of Medicine , Department of Medical Genetics , Istanbul , Turkey
| | - Mehmet Sonmez
- j Karadeniz Technical University Medical Faculty , Department of Internal Medicine , Trabzon , Turkey
| | - Demet Aydin
- k Okmeydani Training and Research Hospital , Department of Hematology , Istanbul , Turkey
| | - Mustafa Pehlivan
- l Gaziantep University Medical Faculty , Department of Internal Medicine , Gaziantep , Turkey
| | - Bulent Undar
- m Dokuz Eylul University Medical Faculty , Department of Internal Medicine , Izmir , Turkey
| | - Simten Dagdas
- n Ankara Numune Training and Research Hospital , Department of Internal Medicine , Ankara , Turkey
| | - Orhan Ayyildiz
- o Dicle University Medical Faculty Hospital , Department of Internal Medicine , Diyarbakir , Turkey
| | - Gülnur Akin
- p Novartis Pharmaceuticals Corporation , Istanbul , Turkey
| | - Ilkiz M Dag
- p Novartis Pharmaceuticals Corporation , Istanbul , Turkey
| | - Osman Ilhan
- q Ankara University School of Medicine , Department of Hematology , Ankara , Turkey
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Nintedanib decreases muscle fibrosis and improves muscle function in a murine model of dystrophinopathy. Cell Death Dis 2018; 9:776. [PMID: 29991677 PMCID: PMC6039566 DOI: 10.1038/s41419-018-0792-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/24/2018] [Accepted: 06/14/2018] [Indexed: 01/07/2023]
Abstract
Duchenne muscle dystrophy (DMD) is a genetic disorder characterized by progressive skeletal muscle weakness. Dystrophin deficiency induces instability of the sarcolemma during muscle contraction that leads to muscle necrosis and replacement of muscle by fibro-adipose tissue. Several therapies have been developed to counteract the fibrotic process. We report the effects of nintedanib, a tyrosine kinase inhibitor, in the mdx murine model of DMD. Nintedanib reduced proliferation and migration of human fibroblasts in vitro and decreased the expression of fibrotic genes such as COL1A1, COL3A1, FN1, TGFB1, and PDGFA. We treated seven mdx mice with 60 mg/kg/day nintedanib for 1 month. Electrophysiological studies showed an increase in the amplitude of the motor action potentials and an improvement of the morphology of motor unit potentials in the animals treated. Histological studies demonstrated a significant reduction of the fibrotic areas present in the skeletal muscles. Analysis of mRNA expression from muscles of treated mice showed a reduction in Col1a1, Col3a1, Tgfb1, and Pdgfa. Western blot showed a reduction in the expression of collagen I in skeletal muscles. In conclusion, nintedanib reduced the fibrotic process in a murine model of dystrophinopathy after 1 month of treatment, suggesting its potential use as a therapeutic drug in DMD patients.
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45
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Fu Y, Zhang R, Wu Q, Zhang J, Bao L, Li J. Development and evaluation of armored RNA-based standards for quantification of BCR-ABL1 p210/p190 fusion gene transcripts. J Clin Lab Anal 2018; 32:e22612. [PMID: 29959790 DOI: 10.1002/jcla.22612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/08/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Standards play an important role in detection of the BCR-ABL1 fusion gene (FG) transcript. However, the standards widely used in laboratories are mainly based on plasmids or cDNA, which cannot accurately reflect the process of RNA extraction and cDNA synthesis. Therefore, we aimed to develop armored RNA-based standards for p210 and p190 BCR-ABL1FG transcripts' quantification. METHODS Using overlapping polymerase chain reaction (PCR) technology, we first linked a segment of the p210 or p190 BCR-ABL1FG transcript with four control genes (CGs; ABL1, BCR, GUSB, and B2M) to form p210FG-CG and p190FG-CG. Subsequently, using armored RNA technology, we prepared p210FG-CG- and p190FG-CG-armored RNAs and the p210FG-CG and p190FG-CG standards, the values of which were assigned by digital PCR (dPCR). RESULTS The p210FG-CG and p190FG-CG standards were stable and homogeneous, and were significantly linear with r2 > 0.98. A field trial including 52 laboratories across China showed that the coefficient of variation (CV%) of BCR-ABL1 values among samples was in the range of 58.6%-129.6% for p210 samples and 73.2%-194.0% for p190 samples when using local standards. By contrast, when using the p210FG-CG and p190FG-CG standards, the CV% of BCR-ABL1 values was decreased to 35.6%-124.9% and 36.6%-170.6% for p210 and p190 samples, respectively. In addition, 33.3% (3/9) of the p210 and p190 samples had CV% values <50.0%, whereas 44.4% (4/9) and 77.8% (7/9) of the samples had lower CV% values when using the p210FG-CG and p190FG-CG standards. CONCLUSION The overall variability of detection of BCR-ABL1 transcripts decreased significantly when using the p210FG-CG or p190FG-CG standards, especially the p190FG-CG standard.
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Affiliation(s)
- Yu Fu
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Rui Zhang
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Qisheng Wu
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Jiawei Zhang
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Lihua Bao
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinming Li
- National Center for Clinical Laboratories, Beijing Hospital, National Center of Gerontology, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
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46
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Medeiros BC, Possick J, Fradley M. Cardiovascular, pulmonary, and metabolic toxicities complicating tyrosine kinase inhibitor therapy in chronic myeloid leukemia: Strategies for monitoring, detecting, and managing. Blood Rev 2018; 32:289-299. [DOI: 10.1016/j.blre.2018.01.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/02/2018] [Accepted: 01/25/2018] [Indexed: 12/19/2022]
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Shin J, Koh Y, Yoon SH, Cho JY, Kim DY, Lee KH, Kim HJ, Ahn JS, Kim YK, Park J, Sohn SK, Moon JH, Lee YJ, Yoon S, Lee JO, Cheong JW, Kim KH, Kim SH, Kim HG, Kim H, Nam SH, Do YR, Park SG, Park SK, Bae SH, Song HH, Shin DY, Oh D, Kim MK, Jung CW, Park S, Kim I. A phase 4 study of nilotinib in Korean patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase: ENESTKorea. Cancer Med 2018; 7:1814-1823. [PMID: 29577674 PMCID: PMC5943463 DOI: 10.1002/cam4.1450] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/12/2018] [Accepted: 02/26/2018] [Indexed: 11/12/2022] Open
Abstract
Although nilotinib has improved efficacy compared to imatinib, suboptimal response and intolerable adverse events (AEs) limit its effectiveness in many patients with chronic myeloid leukemia in chronic phase (CML-CP). We investigated the 2-year efficacy and safety of nilotinib and their relationships with plasma nilotinib concentrations (PNCs). In this open-label, multi-institutional phase 4 study, 110 Philadelphia chromosome-positive CML-CP patients were treated with nilotinib at a starting dose of 300 mg twice daily. Molecular responses (MRs) and AEs were monitored for up to 24 months. The 24-month cumulative MR4.5 rate was evaluated as the primary endpoint. Plasma samples were collected from 94 patients to determine PNCs, and the per-patient mean was used to categorize them into four mean PNC (MPNC) groups. Cumulative MR rates and safety were compared between groups. With a median follow-up of 22.2 months, the 24-month cumulative MR4.5 rate was 56.2% (95% confidence interval, 44.0%-8.3%), and the median time to MR4.5 was 23.3 months. There were no significant differences in the cumulative rates of major molecular response, MR4 , and MR4.5 between MPNC groups. One patient died due to acute viral hepatitis, and two developed hematological or cytogenetic relapse, while no progression to accelerated or blast phase was observed. Safety results were consistent with previous studies with no new safety signal identified. Across the MPNC groups, there was no significant linear trend in the frequency of AEs. Nilotinib is highly effective for the treatment of CML-CP with manageable AEs. The measurement of PNC has no predictive value for patient outcomes and is thus not found to be clinically useful. This study is registered with clinicaltrials.gov, Number NCT03332511.
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Affiliation(s)
- Junghoon Shin
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seo Hyun Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul, Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Hyeong-Joon Kim
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Sook Ahn
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yeo-Kyeoung Kim
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jinny Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sang-Kyun Sohn
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Seonghae Yoon
- Clinical Trials Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - June-Won Cheong
- Department of Internal Medicine, Severance Hospital, Seoul, Korea
| | - Kyoung Ha Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Hoon-Gu Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hawk Kim
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Seung-Hyun Nam
- Department of Internal Medicine, VHS Medical Center, Seoul, Korea
| | - Young Rok Do
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sang-Gon Park
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Seong Kyu Park
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Hun Ho Song
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Min Kyoung Kim
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Chul Won Jung
- Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Defining therapy goals for major molecular remission in chronic myeloid leukemia: results of the randomized CML Study IV. Leukemia 2018; 32:1222-1228. [PMID: 29479070 PMCID: PMC5940636 DOI: 10.1038/s41375-018-0055-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/08/2018] [Accepted: 01/15/2018] [Indexed: 12/12/2022]
Abstract
Major molecular remission (MMR) is an important therapy goal in chronic myeloid leukemia (CML). So far, MMR is not a failure criterion according to ELN management recommendation leading to uncertainties when to change therapy in CML patients not reaching MMR after 12 months. At monthly landmarks, for different molecular remission status Hazard ratios (HR) were estimated for patients registered to CML study IV who were divided in a learning and a validation sample. The minimum HR for MMR was found at 2.5 years with 0.28 (compared to patients without remission). In the validation sample, a significant advantage for progression-free survival (PFS) for patients in MMR could be detected (p-value 0.007). The optimal time to predict PFS in patients with MMR could be validated in an independent sample at 2.5 years. With our model we provide a suggestion when to define lack of MMR as therapy failure and thus treatment change should be considered. The optimal response time for 1% BCR-ABL at about 12–15 months was confirmed and for deep molecular remission no specific time point was detected. Nevertheless, it was demonstrated that the earlier the MMR is achieved the higher is the chance to attain deep molecular response later.
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Breccia M, Palandri F, Luciano L, Benevolo G, Bonifacio M, Caocci G, Castagnetti F, Palumbo GA, Iurlo A, Landi F. Identification and assessment of frailty in older patients with chronic myeloid leukemia and myelofibrosis, and indications for tyrosine kinase inhibitor treatment. Ann Hematol 2018; 97:745-754. [DOI: 10.1007/s00277-018-3258-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/23/2018] [Indexed: 12/27/2022]
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50
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Tokuhira M, Kimura Y, Sugimoto K, Nakazato T, Ishikawa M, Fujioka I, Takaku T, Iriyama N, Sato E, Fujita H, Hatta Y, Komatsu N, Asou N, Kizaki M, Kawaguchi T. Efficacy and safety of nilotinib therapy in patients with newly diagnosed chronic myeloid leukemia in the chronic phase. Med Oncol 2018; 35:38. [PMID: 29442179 DOI: 10.1007/s12032-018-1093-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/31/2018] [Indexed: 01/28/2023]
Abstract
ABL1-tyrosine kinase inhibitors (TKIs) have led to dramatic changes in treatment strategies for chronic myeloid leukemia in the chronic phase (CML-CP). However, clinical studies have highlighted increasing numbers of adverse events (AE) with TKIs. Although TKI modification plays a key role in AE management, this process is poorly understood, particularly in terms of the TKI nilotinib. In the present study, we retrospectively analyzed the records of 70 patients with newly diagnosed (ND)-CML-CP who were treated with nilotinib to investigate the drug potency of nilotinib and treatment management. During a median observation period of 3.4 years, 76% of patients continued nilotinib as a first-line treatment. The 1-year and overall major molecular response (MMR) rates and the overall molecular response (MR) 4.5 rate for all patients receiving first-line nilotinib therapy were 70, 84.2, and 50%, respectively. No case progressed to the accelerated or blast phase during the study. To avoid AEs during the early phase, nilotinib doses were reduced to < 600 mg/day in a third of patients (Reduced group); these patients experienced better therapeutic efficacy and a lower rate of AEs relative to those in Standard group (300 mg twice daily). Ten patients who received < 600 mg/day of nilotinib throughout the study had a 1-year MMR rate and overall MR4.5 rate of 90 and 60%, respectively. In summary, our findings indicate that careful management, including dose reduction, can yield better outcomes in patients with ND-CML-CP.
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Affiliation(s)
- Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Yuta Kimura
- Department of Hematology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Keiji Sugimoto
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Maho Ishikawa
- Department of Hemato-Oncology, Comprehensive Cancer Center, Saitama International Medical Center, Saitama Medical University, Saitama, Japan
| | - Isao Fujioka
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomoiku Takaku
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Eriko Sato
- Division of Hematology, Department of Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Yoshihiro Hatta
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Asou
- Department of Hemato-Oncology, Comprehensive Cancer Center, Saitama International Medical Center, Saitama Medical University, Saitama, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Tatsuya Kawaguchi
- Department of Hematology and Infectious Diseases, Kumamoto University Hospital, Kumamoto, Japan
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