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Cobaleda C, Vicente-Dueñas C, Nichols KE, Sanchez-Garcia I. Childhood B cell leukemia: Intercepting the paths to progression. Bioessays 2024; 46:e2400033. [PMID: 39058907 DOI: 10.1002/bies.202400033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
B-cell Acute Lymphoblastic Leukemia (B-ALL) is the most common pediatric cancer, arising most often in children aged 2-5 years. This distinctive age distribution hints at an association between B-ALL development and disrupted immune system function during a susceptible period during childhood, possibly triggered by early exposure to infection. While cure rates for childhood B-ALL surpass 90% in high-income nations, survivors suffer from diminished quality of life due to the side effects of treatment. Consequently, understanding the origins and evolution of B-ALL, and how to prevent this prevalent childhood cancer, is paramount to alleviate this substantial health burden. This article provides an overview of our current understanding of the etiology of childhood B-ALL and explores how this knowledge can inform preventive strategies.
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Affiliation(s)
- Cesar Cobaleda
- Immune System Development and Function Unit, Centro de Biología Molecular Severo Ochoa (CBM, CSIC-UAM), Madrid, Spain
| | - Carolina Vicente-Dueñas
- Institute for Biomedical Research of Salamanca (IBSAL), Department of Pediatrics, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Kim E Nichols
- Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Isidro Sanchez-Garcia
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
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2
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Farrokhi A, Atre T, Salitra S, Aletaha M, Márquez AC, Gynn M, Fidanza M, Jo S, Rolf N, Simmons K, Duque-Afonso J, Cleary ML, Seif AE, Kollmann T, Gantt S, Reid GSD. Early-life infection depletes preleukemic cells in a mouse model of hyperdiploid B-cell acute lymphoblastic leukemia. Blood 2024; 144:809-821. [PMID: 38875504 PMCID: PMC11375503 DOI: 10.1182/blood.2024025038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024] Open
Abstract
ABSTRACT Epidemiological studies report opposing influences of infection on childhood B-cell acute lymphoblastic leukemia (B-ALL). Although infections in the first year of life appear to exert the largest impact on leukemia risk, the effect of early pathogen exposure on the fetal preleukemia cells (PLC) that lead to B-ALL has yet to be reported. Using cytomegalovirus (CMV) infection as a model early-life infection, we show that virus exposure within 1 week of birth induces profound depletion of transplanted E2A-PBX1 and hyperdiploid B-ALL cells in wild-type recipients and in situ-generated PLC in Eμ-ret mice. The age-dependent depletion of PLC results from an elevated STAT4-mediated cytokine response in neonates, with high levels of interleukin (IL)-12p40-driven interferon (IFN)-γ production inducing PLC death. Similar PLC depletion can be achieved in adult mice by impairing viral clearance. These findings provide mechanistic support for potential inhibitory effects of early-life infection on B-ALL progression and could inform novel therapeutic or preventive strategies.
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Affiliation(s)
- Ali Farrokhi
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Tanmaya Atre
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Samuel Salitra
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Maryam Aletaha
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Ana Citlali Márquez
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Matthew Gynn
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Mario Fidanza
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Sumin Jo
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Nina Rolf
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Karen Simmons
- Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada
| | - Jesus Duque-Afonso
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Michael L Cleary
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Alix E Seif
- Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA
| | - Tobias Kollmann
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Soren Gantt
- Department of Microbiology, Infection, and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Gregor S D Reid
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Division of Oncology, Hematology and Bone Marrow Transplant, Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada
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3
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Garcia C, Miller-Awe MD, Witkowski MT. Concepts in B cell acute lymphoblastic leukemia pathogenesis. J Leukoc Biol 2024; 116:18-32. [PMID: 38243586 DOI: 10.1093/jleuko/qiae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024] Open
Abstract
B cell acute lymphoblastic leukemia (B-ALL) arises from genetic alterations impacting B cell progenitors, ultimately leading to clinically overt disease. Extensive collaborative efforts in basic and clinical research have significantly improved patient prognoses. Nevertheless, a subset of patients demonstrate resistance to conventional chemotherapeutic approaches and emerging immunotherapeutic interventions. This review highlights the mechanistic underpinnings governing B-ALL transformation. Beginning with exploring normative B cell lymphopoiesis, we delineate the influence of recurrent germline and somatic genetic aberrations on the perturbation of B cell progenitor differentiation and protumorigenic signaling, thereby facilitating the neoplastic transformation underlying B-ALL progression. Additionally, we highlight recent advances in the multifaceted landscape of B-ALL, encompassing metabolic reprogramming, microbiome influences, inflammation, and the discernible impact of socioeconomic and racial disparities on B-ALL transformation and patient survival.
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Affiliation(s)
- Clarissa Garcia
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, 12800 East 19th Avenue, Aurora, CO 80045, United States
| | - Megan D Miller-Awe
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, 12800 East 19th Avenue, Aurora, CO 80045, United States
| | - Matthew T Witkowski
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, 12800 East 19th Avenue, Aurora, CO 80045, United States
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4
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Atre T, Farrokhi A, Jo S, Salitra S, Duque-Afonso J, Cleary ML, Rolf N, Reid GSD. Age and ligand specificity influence the outcome of pathogen engagement on preleukemic and leukemic B-cell precursor populations. Blood Adv 2023; 7:7087-7099. [PMID: 37824841 PMCID: PMC10694525 DOI: 10.1182/bloodadvances.2023010782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023] Open
Abstract
Common infections have long been proposed to play a role in the development of pediatric B-cell acute lymphoblastic leukemia (B-ALL). However, epidemiologic studies report contradictory effects of infection exposure on subsequent B-ALL risk, and no specific pathogen has been definitively linked to the disease. A unifying mechanism to explain the divergent outcomes could inform disease prevention strategies. We previously reported that the pattern recognition receptor (PRR) ligand Poly(I:C) exerted effects on B-ALL cells that were distinct from those observed with other nucleic acid-based PRR ligands. Here, using multiple double-stranded RNA (dsRNA) moieties, we show that the overall outcome of exposure to Poly(I:C) reflects the balance of opposing responses induced by its ligation to endosomal and cytoplasmic receptors. This PRR response biology is shared between mouse and human B-ALL and can increase leukemia-initiating cell burden in vivo during the preleukemia phase of B-ALL, primarily through tumor necrosis factor α signaling. The age of the responding immune system further influences the impact of dsRNA exposure on B-ALL cells in both mouse and human settings. Overall, our study demonstrates that potentially proleukemic and antileukemic effects can each be generated by the stimulation of pathogen recognition pathways and indicates a mechanistic explanation for the contrasting epidemiologic associations reported for infection exposure and B-ALL.
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Affiliation(s)
- Tanmaya Atre
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Ali Farrokhi
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Sumin Jo
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Samuel Salitra
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Jesus Duque-Afonso
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Michael L. Cleary
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Nina Rolf
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Gregor S. D. Reid
- Michael Cuccione Childhood Cancer Research Program, BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
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5
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Isidro-Hernández M, Casado-García A, Oak N, Alemán-Arteaga S, Ruiz-Corzo B, Martínez-Cano J, Mayado A, Sánchez EG, Blanco O, Gaspar ML, Orfao A, Alonso-López D, De Las Rivas J, Riesco S, Prieto-Matos P, González-Murillo Á, Criado FJG, Cenador MBG, Ramírez-Orellana M, de Andrés B, Vicente-Dueñas C, Cobaleda C, Nichols KE, Sánchez-García I. Immune stress suppresses innate immune signaling in preleukemic precursor B-cells to provoke leukemia in predisposed mice. Nat Commun 2023; 14:5159. [PMID: 37620322 PMCID: PMC10449887 DOI: 10.1038/s41467-023-40961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023] Open
Abstract
The initial steps of B-cell acute lymphoblastic leukemia (B-ALL) development usually pass unnoticed in children. Several preclinical studies have shown that exposure to immune stressors triggers the transformation of preleukemic B cells to full-blown B-ALL, but how this takes place is still a longstanding and unsolved challenge. Here we show that dysregulation of innate immunity plays a driving role in the clonal evolution of pre-malignant Pax5+/- B-cell precursors toward leukemia. Transcriptional profiling reveals that Myd88 is downregulated in immune-stressed pre-malignant B-cell precursors and in leukemic cells. Genetic reduction of Myd88 expression leads to a significant increase in leukemia incidence in Pax5+/-Myd88+/- mice through an inflammation-dependent mechanism. Early induction of Myd88-independent Toll-like receptor 3 signaling results in a significant delay of leukemia development in Pax5+/- mice. Altogether, these findings identify a role for innate immunity dysregulation in leukemia, with important implications for understanding and therapeutic targeting of the preleukemic state in children.
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Affiliation(s)
- Marta Isidro-Hernández
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Campus M. de Unamuno s/n, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Ana Casado-García
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Campus M. de Unamuno s/n, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Ninad Oak
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Silvia Alemán-Arteaga
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Campus M. de Unamuno s/n, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Belén Ruiz-Corzo
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Campus M. de Unamuno s/n, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Jorge Martínez-Cano
- Immune system development and function Unit, Centro de Biología Molecular Severo Ochoa (Consejo Superior de Investigaciones Científicas -Universidad Autónoma de Madrid), Madrid, Spain
| | - Andrea Mayado
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Servicio de Citometría, Departamento de Medicina, Biomedical Research Networking Centre on Cancer CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, and Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
| | - Elena G Sánchez
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Oscar Blanco
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Anatomía Patológica, Universidad de Salamanca, Salamanca, Spain
| | - Ma Luisa Gaspar
- Immunobiology Department, Carlos III Health Institute, 28220, Majadahonda (Madrid), Spain
| | - Alberto Orfao
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Servicio de Citometría, Departamento de Medicina, Biomedical Research Networking Centre on Cancer CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, and Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
| | - Diego Alonso-López
- Bioinformatics Unit, Cancer Research Center (CSIC-USAL), Salamanca, Spain
| | - Javier De Las Rivas
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Bioinformatics and Functional Genomics Research Group, Cancer Research Center (CSIC-USAL), Salamanca, Spain
| | - Susana Riesco
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58-182, Salamanca, 37007, Spain
| | - Pablo Prieto-Matos
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58-182, Salamanca, 37007, Spain
| | - África González-Murillo
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francisco Javier García Criado
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Cirugía, , Universidad de Salamanca, Salamanca, Spain
| | - María Begoña García Cenador
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Cirugía, , Universidad de Salamanca, Salamanca, Spain
| | - Manuel Ramírez-Orellana
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Belén de Andrés
- Immunobiology Department, Carlos III Health Institute, 28220, Majadahonda (Madrid), Spain
| | - Carolina Vicente-Dueñas
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58-182, Salamanca, 37007, Spain.
| | - César Cobaleda
- Immune system development and function Unit, Centro de Biología Molecular Severo Ochoa (Consejo Superior de Investigaciones Científicas -Universidad Autónoma de Madrid), Madrid, Spain.
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Isidro Sánchez-García
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Campus M. de Unamuno s/n, Salamanca, Spain.
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.
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6
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Peppas I, Ford AM, Furness CL, Greaves MF. Gut microbiome immaturity and childhood acute lymphoblastic leukaemia. Nat Rev Cancer 2023; 23:565-576. [PMID: 37280427 PMCID: PMC10243253 DOI: 10.1038/s41568-023-00584-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
Acute lymphoblastic leukaemia (ALL) is the most common cancer of childhood. Here, we map emerging evidence suggesting that children with ALL at the time of diagnosis may have a delayed maturation of the gut microbiome compared with healthy children. This finding may be associated with early-life epidemiological factors previously identified as risk indicators for childhood ALL, including caesarean section birth, diminished breast feeding and paucity of social contacts. The consistently observed deficiency in short-chain fatty-acid-producing bacterial taxa in children with ALL has the potential to promote dysregulated immune responses and to, ultimately, increase the risk of transformation of preleukaemic clones in response to common infectious triggers. These data endorse the concept that a microbiome deficit in early life may contribute to the development of the major subtypes of childhood ALL and encourage the notion of risk-reducing microbiome-targeted intervention in the future.
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Affiliation(s)
- Ioannis Peppas
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK
- Department of Paediatric Oncology, The Royal Marsden Hospital Sutton, Surrey, UK
| | - Anthony M Ford
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK
| | - Caroline L Furness
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK
- Department of Paediatric Oncology, The Royal Marsden Hospital Sutton, Surrey, UK
| | - Mel F Greaves
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK.
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7
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Casado-García A, Isidro-Hernández M, Oak N, Mayado A, Mann-Ran C, Raboso-Gallego J, Alemán-Arteaga S, Buhles A, Sterker D, Sánchez EG, Martínez-Cano J, Blanco O, Orfao A, Alonso-López D, De Las Rivas J, Riesco S, Prieto-Matos P, González-Murillo Á, García Criado FJ, García Cenador MB, Radimerski T, Ramírez-Orellana M, Cobaleda C, Yang JJ, Vicente-Dueñas C, Weiss A, Nichols KE, Sánchez-García I. Transient Inhibition of the JAK/STAT Pathway Prevents B-ALL Development in Genetically Predisposed Mice. Cancer Res 2022; 82:1098-1109. [PMID: 35131871 PMCID: PMC9359729 DOI: 10.1158/0008-5472.can-21-3386] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 01/07/2023]
Abstract
Preventing development of childhood B-cell acute lymphoblastic leukemia (B-ALL), a disease with devastating effects, is a longstanding and unsolved challenge. Heterozygous germline alterations in the PAX5 gene can lead to B-ALL upon accumulation of secondary mutations affecting the JAK/STAT signaling pathway. Preclinical studies have shown that this malignant transformation occurs only under immune stress such as exposure to infectious pathogens. Here we show in Pax5+/- mice that transient, early-life administration of clinically relevant doses of ruxolitinib, a JAK1/2 inhibitor, significantly mitigates the risk of B-ALL following exposure to infection; 1 of 29 animals treated with ruxolitinib developed B-ALL versus 8 of 34 untreated mice. Ruxolitinib treatment preferentially targeted Pax5+/- versus wild-type B-cell progenitors and exerted unique effects on the Pax5+/- B-cell progenitor transcriptional program. These findings provide the first in vivo evidence for a potential strategy to prevent B-ALL development. SIGNIFICANCE JAK/STAT inhibition suppresses tumorigenesis in a B-ALL-susceptible mouse model, presenting a novel approach to prevent B-ALL onset.
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Affiliation(s)
- Ana Casado-García
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Marta Isidro-Hernández
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Ninad Oak
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Andrea Mayado
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Servicio de Citometría, Departamento de Medicina, Biomedical Research Networking Centre on Cancer CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, and Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
| | - Christine Mann-Ran
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Javier Raboso-Gallego
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Silvia Alemán-Arteaga
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Alexandra Buhles
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Dario Sterker
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Elena G. Sánchez
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Jorge Martínez-Cano
- Immune system development and function Unit, Centro de Biología Molecular Severo Ochoa (Consejo Superior de Investigaciones Científicas -Universidad Autónoma de Madrid), Madrid, Spain
| | - Oscar Blanco
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Anatomía Patológica, Universidad de Salamanca, Salamanca, Spain
| | - Alberto Orfao
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Servicio de Citometría, Departamento de Medicina, Biomedical Research Networking Centre on Cancer CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, and Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
| | - Diego Alonso-López
- Bioinformatics Unit, Cancer Research Center (CSIC-USAL), Salamanca, Spain
| | - Javier De Las Rivas
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Bioinformatics and Functional Genomics Research Group, Cancer Research Center (CSIC-USAL), Salamanca, Spain
| | - Susana Riesco
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58–182, Salamanca, Spain
| | - Pablo Prieto-Matos
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58–182, Salamanca, Spain
| | - África González-Murillo
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francisco Javier García Criado
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Cirugía, Universidad de Salamanca, Salamanca, Spain
| | - María Begoña García Cenador
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Cirugía, Universidad de Salamanca, Salamanca, Spain
| | - Thomas Radimerski
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Manuel Ramírez-Orellana
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - César Cobaleda
- Immune system development and function Unit, Centro de Biología Molecular Severo Ochoa (Consejo Superior de Investigaciones Científicas -Universidad Autónoma de Madrid), Madrid, Spain
| | - Jun J. Yang
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carolina Vicente-Dueñas
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Pediatrics, Hospital Universitario de Salamanca, Paseo de San Vicente, 58–182, Salamanca, Spain
| | - Andreas Weiss
- Novartis Institutes for BioMedical Research, Novartis Campus, Basel, Switzerland
| | - Kim E. Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Isidro Sánchez-García
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
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8
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Cardesa-Salzmann TM, Simon A, Graf N. Antibiotics in early life and childhood pre-B-ALL. Reasons to analyze a possible new piece in the puzzle. Discov Oncol 2022; 13:5. [PMID: 35201533 PMCID: PMC8777491 DOI: 10.1007/s12672-022-00465-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer with precursor B-cell ALL (pB-ALL) accounting for ~ 85% of the cases. Childhood pB-ALL development is influenced by genetic susceptibility and host immune responses. The role of the intestinal microbiome in leukemogenesis is gaining increasing attention since Vicente-Dueñas' seminal work demonstrated that the gut microbiome is distinct in mice genetically predisposed to ALL and that the alteration of this microbiome by antibiotics is able to trigger pB-ALL in Pax5 heterozygous mice in the absence of infectious stimuli. In this review we provide an overview on novel insights on the role of the microbiome in normal and preleukemic hematopoiesis, inflammation, the effect of dysbiosis on hematopoietic stem cells and the emerging importance of the innate immune responses in the conversion from preleukemic to leukemic state in childhood ALL. Since antibiotics, which represent one of the most widely used medical interventions, alter the gut microbial composition and can cause a state of dysbiosis, this raises exciting epidemiological questions regarding the implications for antibiotic use in early life, especially in infants with a a preleukemic "first hit". Sheading light through a rigorous study on this piece of the puzzle may have broad implications for clinical practice.
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Affiliation(s)
- T. M. Cardesa-Salzmann
- Department of Pediatric Hematology and Oncology, Universitätsklinikum des Saarlandes, Homburg, Saarland Germany
| | - A. Simon
- Department of Pediatric Hematology and Oncology, Universitätsklinikum des Saarlandes, Homburg, Saarland Germany
| | - N. Graf
- Department of Pediatric Hematology and Oncology, Universitätsklinikum des Saarlandes, Homburg, Saarland Germany
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9
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Elevated blood MxA protein levels in children with newly diagnosed B-ALL: A prospective case-control study. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1033655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Hauer J, Fischer U, Borkhardt A. Toward prevention of childhood ALL by early-life immune training. Blood 2021; 138:1412-1428. [PMID: 34010407 PMCID: PMC8532195 DOI: 10.1182/blood.2020009895] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/21/2021] [Indexed: 11/21/2022] Open
Abstract
B-cell precursor acute lymphoblastic leukemia (BCP-ALL) is the most common form of childhood cancer. Chemotherapy is associated with life-long health sequelae and fails in ∼20% of cases. Thus, prevention of leukemia would be preferable to treatment. Childhood leukemia frequently starts before birth, during fetal hematopoiesis. A first genetic hit (eg, the ETV6-RUNX1 gene fusion) leads to the expansion of preleukemic B-cell clones, which are detectable in healthy newborn cord blood (up to 5%). These preleukemic clones give rise to clinically overt leukemia in only ∼0.2% of carriers. Experimental evidence suggests that a major driver of conversion from the preleukemic to the leukemic state is exposure to immune challenges. Novel insights have shed light on immune host responses and how they shape the complex interplay between (1) inherited or acquired genetic predispositions, (2) exposure to infection, and (3) abnormal cytokine release from immunologically untrained cells. Here, we integrate the recently emerging concept of "trained immunity" into existing models of childhood BCP-ALL and suggest future avenues toward leukemia prevention.
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Affiliation(s)
- Julia Hauer
- National Center for Tumor Diseases (NCT), Dresden, Germany
- Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Ute Fischer
- Department for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany; and
- German Cancer Consortium (DKTK), partnering site Essen/Düsseldorf, Germany
| | - Arndt Borkhardt
- Department for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany; and
- German Cancer Consortium (DKTK), partnering site Essen/Düsseldorf, Germany
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11
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Cobaleda C, Vicente-Dueñas C, Sanchez-Garcia I. Infectious triggers and novel therapeutic opportunities in childhood B cell leukaemia. Nat Rev Immunol 2021; 21:570-581. [PMID: 33558682 DOI: 10.1038/s41577-021-00505-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/30/2023]
Abstract
B cell acute lymphoblastic leukaemia (B-ALL) is the most common form of childhood cancer. Although treatment has advanced remarkably in the past 50 years, it still fails in ~20% of patients. Recent studies revealed that more than 5% of healthy newborns carry preleukaemic clones that originate in utero, but only a small percentage of these carriers will progress to overt B-ALL. The drivers of progression are unclear, but B-ALL incidence seems to be increasing in parallel with the adoption of modern lifestyles. Emerging evidence shows that a major driver for the conversion from the preleukaemic state to the B-ALL state is exposure to immune stressors, such as infection. Here, we discuss our current understanding of the environmental triggers and genetic predispositions that may lead to B-ALL, highlighting lessons from epidemiology, the clinic and animal models, and identifying priority areas for future research.
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Affiliation(s)
- Cesar Cobaleda
- Immune System Development and Function Unit, Centro de Biología Molecular Severo Ochoa, CSIC and Universidad Autónoma de Madrid, Madrid, Spain.
| | | | - Isidro Sanchez-Garcia
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain. .,Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC and Universidad de Salamanca, Salamanca, Spain.
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12
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Cobaleda C, Vicente-Dueñas C, Sánchez-García I. An immune window of opportunity to prevent childhood B cell leukemia. Trends Immunol 2021; 42:371-374. [PMID: 33773925 DOI: 10.1016/j.it.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of childhood B cell acute lymphoblastic leukemia (B-ALL) is increasing, particularly in developed countries. There is no clear explanation for this increment, but recent data suggest that, besides genetic predisposition, stress in the immune system (e.g., an infection) might have an important role in B-ALL leukemogenesis. Here, we speculate on how this knowledge might impact B-ALL prevention strategies.
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Affiliation(s)
- César Cobaleda
- Immune System Development and Function Unit, Centro de Biología Molecular Severo Ochoa (CSIC -Universidad Autónoma de Madrid), Madrid, Spain. *
| | | | - Isidro Sánchez-García
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain.
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13
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Inhibition of inflammatory signaling in Pax5 mutant cells mitigates B-cell leukemogenesis. Sci Rep 2020; 10:19189. [PMID: 33154497 PMCID: PMC7644722 DOI: 10.1038/s41598-020-76206-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022] Open
Abstract
PAX5 is one of the most frequently mutated genes in B-cell acute lymphoblastic leukemia (B-ALL), and children with inherited preleukemic PAX5 mutations are at a higher risk of developing the disease. Abnormal profiles of inflammatory markers have been detected in neonatal blood spot samples of children who later developed B-ALL. However, how inflammatory signals contribute to B-ALL development is unclear. Here, we demonstrate that Pax5 heterozygosis, in the presence of infections, results in the enhanced production of the inflammatory cytokine interleukin-6 (IL-6), which appears to act in an autocrine fashion to promote leukemia growth. Furthermore, in vivo genetic downregulation of IL-6 in these Pax5 heterozygous mice retards B-cell leukemogenesis, and in vivo pharmacologic inhibition of IL-6 with a neutralizing antibody in Pax5 mutant mice with B-ALL clears leukemic cells. Additionally, this novel IL–6 signaling paradigm identified in mice was also substantiated in humans. Altogether, our studies establish aberrant IL6 expression caused by Pax5 loss as a hallmark of Pax5-dependent B-ALL and the IL6 as a therapeutic vulnerability for B-ALL characterized by PAX5 loss.
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14
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Ge XJ, Wang YL, Wu YP, Feng ZX, Liu L, Li MY, Jiang JY. Regulatory effect of Act1 on the BAFF pathway in B-cell malignancy. Oncol Lett 2019; 17:3727-3734. [PMID: 30930983 PMCID: PMC6425348 DOI: 10.3892/ol.2019.10047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/25/2019] [Indexed: 02/05/2023] Open
Abstract
The aim of the present study was to ascertain whether nuclear factor (NF)-κB Activator 1 (Act1) was involved in B cell-activating factor (BAFF) regulation in B-cell malignancy. The human B-cell malignancy cell lines Raji, Daudi and BALL-1 were cultured and the expression of BAFF receptor (BAFF-R) mRNA and protein was analyzed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blotting, respectively. NF-κB signaling was also assessed using western blotting. Act1 silencing was performed using Act1 small interfering RNA. BAFF-R levels were assessed using flow cytometry. It was demonstrated that BAFF-R was upregulated in all three cell lines and RT-qPCR, and western blotting confirmed these results. Act1 overexpression was demonstrated to induce BAFF-R upregulation, whereas Act1 knockdown resulted in BAFF-R downregulation. Furthermore, the NF-κB pathway was activated by Act1 overexpression and inhibited following Act1 knockdown. The results of the present study demonstrated that Act1 can regulate BAFF via targeting NF-κB signaling, which suggests that Act1 may be a promising therapeutic target for the treatment of B-cell malignancy.
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Affiliation(s)
- Xiao-Jun Ge
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, P.R. China
| | - Yong-Lun Wang
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, P.R. China
| | - Yang Ping Wu
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Zhong-Xin Feng
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, P.R. China
| | - Lan Liu
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, P.R. China
| | - Mei Yong Li
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Jun-Yao Jiang
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563003, P.R. China
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15
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Abstract
In this Review, I present evidence supporting a multifactorial causation of childhood acute lymphoblastic leukaemia (ALL), a major subtype of paediatric cancer. ALL evolves in two discrete steps. First, in utero initiation by fusion gene formation or hyperdiploidy generates a covert, pre-leukaemic clone. Second, in a small fraction of these cases, the postnatal acquisition of secondary genetic changes (primarily V(D)J recombination-activating protein (RAG) and activation-induced cytidine deaminase (AID)-driven copy number alterations in the case of ETS translocation variant 6 (ETV6)-runt-related transcription factor 1 (RUNX1)+ ALL) drives conversion to overt leukaemia. Epidemiological and modelling studies endorse a dual role for common infections. Microbial exposures earlier in life are protective but, in their absence, later infections trigger the critical secondary mutations. Risk is further modified by inherited genetics, chance and, probably, diet. Childhood ALL can be viewed as a paradoxical consequence of progress in modern societies, where behavioural changes have restrained early microbial exposure. This engenders an evolutionary mismatch between historical adaptations of the immune system and contemporary lifestyles. Childhood ALL may be a preventable cancer.
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Affiliation(s)
- Mel Greaves
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK.
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16
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Fidanza M, Seif AE, Jo S, Kariminia A, Rolf N, Sly LM, Grupp SA, Reid GSD. IFN-γ directly inhibits murine B-cell precursor leukemia-initiating cell proliferation early in life. Eur J Immunol 2017; 47:892-899. [PMID: 28295300 DOI: 10.1002/eji.201646806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/10/2017] [Accepted: 03/09/2017] [Indexed: 11/07/2022]
Abstract
The early-life immune environment has been implicated as a modulator of acute lymphoblastic leukemia (ALL) development in children, with infection being associated with significant changes in ALL risk. Furthermore, polymorphisms in several cytokine genes, including IL-10 and IFN-γ, are associated with leukemia development. However, the mechanisms and timing of these influences remain unknown. Here, we use the Eμ-ret transgenic mouse model of B-cell precursor ALL to assess the influence of IFN-γ on the early-life burden of leukemia-initiating cells. The absence of IFN-γ activity resulted in greater numbers of leukemia-initiating cells early in life and was associated with accelerated leukemia onset. The leukemia-initiating cells from IFN-γ-knockout mice had reduced suppressor of cytokine signaling (SOCS-1) expression, were significantly more sensitive to IFN-γ, and exhibited more rapid expansion in vivo than their wild-type counterparts. However, sensitivity to this inhibitory pathway was lost in fully transformed IFN-γ-knockout leukemia cells. These results demonstrate that the influence of IFN-γ on ALL progression may not be mediated by selection of nascent transformed cells but rather through a general SOCS-mediated reduction in B-cell precursor proliferation. Thus, while cytokine levels may influence leukemia at multiple points during disease progression, our study indicates a significant early influence of basal, infection-independent cytokine production on leukemogenesis.
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Affiliation(s)
- Mario Fidanza
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Alix E Seif
- Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, PA, USA
- Division of Oncology, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Sumin Jo
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Amina Kariminia
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Nina Rolf
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Laura M Sly
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Stephan A Grupp
- Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, PA, USA
- Division of Oncology, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregor S D Reid
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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17
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Zimmermannova O, Zaliova M, Moorman AV, Al-Shehhi H, Fronkova E, Zemanova Z, Kalina T, Vora A, Stary J, Trka J, Hrusak O, Zuna J. Acute lymphoblastic leukemia with aleukemic prodrome: preleukemic dynamics and possible mechanisms of immunosurveillance. Haematologica 2017; 102:e225-e228. [PMID: 28255018 DOI: 10.3324/haematol.2016.161380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Olga Zimmermannova
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Marketa Zaliova
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Anthony V Moorman
- Leukaemia Research Cytogenetics Group, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Halima Al-Shehhi
- Leukaemia Research Cytogenetics Group, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Eva Fronkova
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Zuzana Zemanova
- Center of Oncocytogenetics, Institute of Clinical Biochemistry and Laboratory Diagnostics, 1 Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Kalina
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Ajay Vora
- Department of Haematology, Sheffield Children's Hospital, UK
| | - Jan Stary
- Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Trka
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Ondrej Hrusak
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Zuna
- CLIP, Childhood Leukaemia Investigation Prague, Czech Republic .,Department of Paediatric Haematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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