1
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Mahon FX, Pfirrmann M, Dulucq S, Hochhaus A, Panayiotidis P, Almeida A, Mayer J, Hjorth-Hansen H, Janssen JJWM, Mustjoki S, Martinez-Lopez J, Vestergaard H, Ehrencrona H, Machová Poláková K, Olsson-Strömberg U, Ossenkoppele G, Berger MG, Etienne G, Dengler J, Brümmendorf TH, Burchert A, Réa D, Rousselot P, Nicolini FE, Hofmann WK, Richter J, Saussele S. European Stop Tyrosine Kinase Inhibitor Trial (EURO-SKI) in Chronic Myeloid Leukemia: Final Analysis and Novel Prognostic Factors for Treatment-Free Remission. J Clin Oncol 2024; 42:1875-1880. [PMID: 38471049 DOI: 10.1200/jco.23.01647] [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: 08/02/2023] [Revised: 11/23/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The European Stop Kinase Inhibitors (EURO-SKI) study is the largest clinical trial for investigating the cessation of tyrosine kinase inhibitors (TKIs) in patients with chronic myeloid leukemia in stable deep molecular remission (DMR). Among 728 patients, 434 patients (61%; 95% CI, 57 to 64) remained in major molecular response (MMR) at 6 months and 309 patients of 678 (46%; 95% CI, 42 to 49) at 36 months. Duration of TKI treatment and DMR before TKI stop were confirmed as significant factors for the prediction of MMR loss at 6 months. In addition, the type of BCR::ABL1 transcript was identified as a prognostic factor. For late MMR losses after 6 months, TKI treatment duration, percentage of blasts in peripheral blood, and platelet count at diagnosis were significant factors in multivariate analysis. For the entire study period of 36 months, multiple logistic regression models confirmed duration of treatment, blasts, and transcript type as independent factors for MMR maintenance. In addition to the duration of treatment, transcript type as well as blasts in peripheral blood at diagnosis should be considered as important factors to predict treatment-free remission.
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Affiliation(s)
- Francois-Xavier Mahon
- Bergonié Cancer Institute, INSERM UMR1312 Inserm, University of Bordeaux, Bordeaux, France
| | - Markus Pfirrmann
- Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie (IBE), Medizinische Fakultät, LMU München, München, Germany
| | - Stéphanie Dulucq
- Laboratory of Hematology, University Hospital of Bordeaux, Hôpital Haut Lévêque, Pessac, France
- Groupe Fi-LMC, Centre Léon Bérard, Lyon, France
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | | | - Antonio Almeida
- Faculdade de Medicina, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | | | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, Location VUMC, Amsterdam, the Netherlands
| | - Satu Mustjoki
- Hematology Research Unit Helsinki and Translational Immunology Research Program, University of Helsinki and Helsinki University Comprehensive Cancer Center, Helsinki, Finland
- ICAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland
| | - Joaquin Martinez-Lopez
- Hospital 12 de Octubre, CNIO, i+12, Department of Medicine Univ. Complutense, Madrid, Spain
| | - Hanne Vestergaard
- Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Hans Ehrencrona
- Department of Genetics and Pathology, Laboratory Medicine, Region Skåne, Lund, Sweden
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | | | - Ulla Olsson-Strömberg
- Department of Medical Science and Division of Hematology, University Hospital, Uppsala, Sweden
| | - Gert Ossenkoppele
- Department of Hematology, Amsterdam UMC, Location VUMC, Amsterdam, the Netherlands
| | - Marc G Berger
- Hématologie Biologique and EA 7453 CHELTER, CHU Estaing and Université Clermont Auvergne, Clermont-Ferrand, France
| | - Gabriel Etienne
- Groupe Fi-LMC, Centre Léon Bérard, Lyon, France
- Hematology Department, Institut Bergonié, Bordeaux, France
| | - Jolanta Dengler
- Onkologische Schwerpunktpraxis Heilbronn, Heilbronn, Germany
- Innere Medizin III, Diakonie-Klinikum, Schwäbisch Hall, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Andreas Burchert
- Department of Hematology, Oncology and Immunology, Philipps University Marburg Faculty of Medicine, Marburg, Germany
| | - Delphine Réa
- Service d'Hématologie Adulte and INSERM UMR-1160, Hôpital Saint-Louis, Paris, France
| | - Philippe Rousselot
- Department of Hematology, Centre Hospitalier de Versailles, INSERM UMR 1184, Université Versailles Paris Saclay, Le Chesnay, France
| | | | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Johan Richter
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Susanne Saussele
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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2
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Wang Y, Liang ZJ, Gale RP, Liao HZ, Ma J, Gong TJ, Shao YQ, Liang Y. Chronic myeloid leukaemia: Biology and therapy. Blood Rev 2024; 65:101196. [PMID: 38604819 DOI: 10.1016/j.blre.2024.101196] [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: 11/30/2023] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
Chronic myeloid leukaemia (CML) is caused by BCR::ABL1. Tyrosine kinase-inhibitors (TKIs) are the initial therapy. Several organizations have reported milestones to evaluate response to initial TKI-therapy and suggest when a change of TKI should be considered. Achieving treatment-free remission (TFR) is increasingly recognized as the optimal therapy goal. Which TKI is the best initial therapy for which persons and what depth and duration of molecular remission is needed to achieve TFR are controversial. In this review we discuss these issues and suggest future research directions.
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MESH Headings
- Humans
- Protein Kinase Inhibitors/therapeutic use
- Fusion Proteins, bcr-abl/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/etiology
- Remission Induction
- Biology
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Affiliation(s)
- Yun Wang
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Zhi-Jian Liang
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Robert Peter Gale
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, China; Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Hua-Ze Liao
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Jun Ma
- Harbin Institute of Hematology and Oncology, Harbin First Hospital, Harbin 150010, China
| | - Tie-Jun Gong
- Harbin Institute of Hematology and Oncology, Harbin First Hospital, Harbin 150010, China.
| | - Ying-Qi Shao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China.
| | - Yang Liang
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Sun Yat-sen University Cancer Center, Guangzhou 510060, China; State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China.
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3
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Lai X, Jiao X, Zhang H, Lei J. Computational modeling reveals key factors driving treatment-free remission in chronic myeloid leukemia patients. NPJ Syst Biol Appl 2024; 10:45. [PMID: 38678088 PMCID: PMC11055880 DOI: 10.1038/s41540-024-00370-4] [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: 04/22/2023] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
Patients with chronic myeloid leukemia (CML) who receive tyrosine kinase inhibitors (TKIs) have been known to achieve treatment-free remission (TFR) upon discontinuing treatment. However, the underlying mechanisms of this phenomenon remain incompletely understood. This study aims to elucidate the mechanism of TFR in CML patients, focusing on the feedback interaction between leukemia stem cells and the bone marrow microenvironment. We have developed a mathematical model to explore the interplay between leukemia stem cells and the bone marrow microenvironment, allowing for the simulation of CML progression dynamics. Our proposed model reveals a dichotomous response following TKI discontinuation, with two distinct patient groups emerging: one prone to early molecular relapse and the other capable of achieving long-term TFR after treatment cessation. This finding aligns with clinical observations and underscores the essential role of feedback interaction between leukemic cells and the tumor microenvironment in sustaining TFR. Notably, we have shown that the ratio of leukemia cells in peripheral blood (PBLC) and the tumor microenvironment (TME) index can be a valuable predictive tool for identifying patients likely to achieve TFR after discontinuing treatment. This study provides fresh insights into the mechanism of TFR in CML patients and underscores the significance of microenvironmental control in achieving TFR.
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Affiliation(s)
- Xiulan Lai
- Institute for Mathematical Sciences, Renmin University of China, Beijing, China
| | - Xiaopei Jiao
- Department of Mathematics, Tsinghua University, Beijing, China
| | - Haojian Zhang
- The State Key Laboratory Breeding Base of Basic Science of Stomatology and Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Medical Research Institute, School of Medicine, Wuhan University, Wuhan, China.
- Frontier Science Center for Immunology and Metabolism, Medical Research Institute, School of Medicine, Wuhan University, Wuhan, China.
| | - Jinzhi Lei
- School of Mathematical Sciences, Center for Applied Mathematics, Tiangong University, Tianjin, China.
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4
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Zhang Z, Zhou X, Zhou X, Cheng Z, Hu Y. Exploration of treatment-free remission in CML, based on molecular monitoring. Cancer Med 2024; 13:e6849. [PMID: 38133525 PMCID: PMC10807643 DOI: 10.1002/cam4.6849] [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: 09/26/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Typical chronic myelogenous leukemia (CML) is a myeloproliferative neoplasm caused by t(9; 22)(q34; q11) translocation. This chromosomal translocation forms the BCR::ABL1 fusion gene. The tyrosine kinase encoded by the BCR::ABL1 is considered to be the main pathogenic diver. BCR::ABL1 is not only a therapeutic target, but also a monitoring target. Monitoring of BCR::ABL1 reveals the progression of the disease and guides the next treatment. Now for CML, the target of treatment has been focused on treatment-free remission (TFR). METHODS We conducted a literature review of current developments of treatment-free remission and molecular monitoring methods. RESULTS More effective and sensitive CML monitoring methods such as digital droplet PCR (ddPCR) and next generation sequencing (NGS) have further studied the measurable residual disease (MRD) and clonal heterogeneity, which provides strong support for the exploration of TFR. We discussed some of the factors that may be related to TFR outcomes at the molecular level, along with some monitoring strategies. CONCLUSION Currently, predictive indicators for treatment-free remission outcomes and recurrence are lacking in clinical practice. In future, treatment-free remission research should focus on combining the clinical indicators with molecular monitoring and biological markers to personalize patient conditions and guide clinicians to develop individualized treatment plans, so that more patients with CML can achieve safer and stabler treatment-free remission.
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MESH Headings
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Remission Induction
- Fusion Proteins, bcr-abl/genetics
- Neoplasm, Residual/genetics
- High-Throughput Nucleotide Sequencing
- Biomarkers, Tumor/genetics
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Affiliation(s)
| | | | - Xin Zhou
- Wuhan Union HospitalWuhanHubeiChina
| | | | - Yu Hu
- Wuhan Union HospitalWuhanHubeiChina
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5
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Pagani IS, Shanmuganathan N, Dang P, Saunders VA, Grose R, Kok CH, James J, Tolland M, Braley JA, Altamura HK, Yeung DT, Branford S, Yong ASM, Hughes TP, Ross DM. Lineage-specific detection of residual disease predicts relapse in patients with chronic myeloid leukemia stopping therapy. Blood 2023; 142:2192-2197. [PMID: 37616555 DOI: 10.1182/blood.2023021119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/03/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
ABSTRACT Patients with chronic myeloid leukemia who are eligible for treatment-free remission (TFR) may still relapse after tyrosine kinase inhibitor (TKI) cessation. There is a need for accurate predictors of outcome to enable patients with a favorable profile to proceed while avoiding futile attempts. Sensitive detection of residual disease in total leukocytes at treatment cessation is associated with relapse but is not highly discriminatory, likely because it is a composite measure of residual leukemia derived from different cell lineages, whereas only some lineages are relevant for relapse. We prospectively measured BCR::ABL1 DNA as a predictive yes/no binary test in 5 cellular fractions from 48 patients meeting conventional criteria for TKI discontinuation. The median BCR::ABL1 DNA level was higher in granulocytes and T cells, but not in other lineages, in patients who relapsed. Among the 40 patients undergoing their first TFR attempt, we defined 3 groups with differing relapse risk: granulocyte-positive group (100%), granulocyte-negative/T-cell-positive group (67%), and granulocyte-negative /T-cell-negative group (25%). These data show the critical importance of lineage-specific assessment of residual disease in the selection of patients who can attempt to achieve TFR with a high expectation of success and, concurrently, defer patients who have a high probability of relapse.
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MESH Headings
- Humans
- Fusion Proteins, bcr-abl/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Protein Kinase Inhibitors
- Recurrence
- Remission Induction
- DNA
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Affiliation(s)
- Ilaria S Pagani
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Naranie Shanmuganathan
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, SA, Australia
- Genetic and Molecular Pathology, SA Pathology, SA, Adelaide, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA, Australia
| | - Phuong Dang
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Verity A Saunders
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Randall Grose
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Chung H Kok
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Jane James
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Molly Tolland
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Jodi A Braley
- Genetic and Molecular Pathology, SA Pathology, SA, Adelaide, Australia
| | - Haley K Altamura
- Genetic and Molecular Pathology, SA Pathology, SA, Adelaide, Australia
| | - David T Yeung
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Susan Branford
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Genetic and Molecular Pathology, SA Pathology, SA, Adelaide, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA, Australia
- Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Agnes S M Yong
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology, Royal Perth Hospital, Perth, WA, Australia
- Discipline of Pathology and Laboratory Medicine, The University of Western Australia Medical School, Perth, WA, Australia
| | - Timothy P Hughes
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David M Ross
- Precision Cancer Medicine Theme, Blood Cancer Program, Chronic Myeloid Leukaemia Research Group, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, SA, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA, Australia
- Department of Haematology and Genetic Pathology, Flinders University and Medical Centre, Adelaide, SA, Australia
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6
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Iurlo A, Cattaneo D, Bucelli C, Spallarossa P, Passamonti F. Cardiovascular Adverse Events of Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: Clinical Relevance, Impact on Outcome, Preventive Measures and Treatment Strategies. Curr Treat Options Oncol 2023; 24:1720-1738. [PMID: 38047977 DOI: 10.1007/s11864-023-01149-1] [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] [Accepted: 11/12/2023] [Indexed: 12/05/2023]
Abstract
OPINION STATEMENT The introduction of TKIs into the therapeutic armamentarium of CML has changed the disease paradigm, increasing long-term survival from 20% to over 80%, with a life expectancy now approaching that of the general population. Although highly effective, TKIs also have a toxicity profile that is often mild to moderate, but sometimes severe, with multiple kinases involved in the development of adverse events (AEs). Among others, cardiovascular AEs observed in TKI-treated CML patients may represent a significant cause of morbidity and mortality, and their pathogenesis is still only partially understood. In view of the recent introduction into daily clinical practice of new TKIs, namely the STAMP inhibitor asciminib, with a distinct safety profile, hematologists now more than ever have the opportunity to select the most suitable TKI for each patient, an aspect that will be fundamental in terms of personalized preventive and therapeutic strategies. Furthermore, physicians should be aware of the feasibility of TKI dose modifications at all stages of the patients' treatment journey, both at diagnosis for frail or elderly subjects or with multiple comorbidities, and during follow-up for those patients who experience toxicity, as well as to prevent it, with the main objective of reducing side effects while maintaining the response. Consequently, preserving the cardiovascular health of CML patients will likely be a more urgent topic in the near future, with specific measures aimed at controlling cardiovascular risk factors through a multidisciplinary approach involving a panel of healthcare professionals together with the hematologist.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy.
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino - Italian IRCCS Cardiology Network, Genova, Italy
| | - Francesco Passamonti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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7
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Zhang J, Ma C, Yu Y, Liu C, Fang L, Rao H. Single amino acid-based PROTACs trigger degradation of the oncogenic kinase BCR-ABL in chronic myeloid leukemia (CML). J Biol Chem 2023; 299:104994. [PMID: 37392851 PMCID: PMC10388202 DOI: 10.1016/j.jbc.2023.104994] [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: 04/22/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023] Open
Abstract
Proteolysis-targeting chimera (PROTAC) that specifically targets harmful proteins for destruction by hijacking the ubiquitin-proteasome system is emerging as a potent anticancer strategy. How to efficiently modulate the target degradation remains a challenging issue. In this study, we employ a single amino acid-based PROTAC, which uses the shortest degradation signal sequence as the ligand of the N-end rule E3 ubiquitin ligases to degrade the fusion protein BCR (breakpoint cluster region)-ABL (Abelson proto-oncogene), an oncogenic kinase that drives the progression of chronic myeloid leukemia. We find that the reduction level of BCR-ABL can be easily adjusted by substituting different amino acids. Furthermore, a single PEG linker is found to achieve the best proteolytic effect. Our efforts have resulted in effective degradation of BCR-ABL protein by the N-end rule pathway and efficient growth inhibition of K562 cells expressing BCR-ABL in vitro and blunted tumor growth in a K562 xenograft tumor model in vivo. The PROTAC presented has unique advantages including lower effective concentration, smaller molecular size, and modular degradation rate. Demonstrating the efficacy of the N-end rule-based PROTACs in vitro and in vivo, our study further expands the limited degradation pathways currently available for PROTACs in vivo and is easily adapted for broader applications in targeted protein degradation.
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MESH Headings
- Humans
- Proteolysis Targeting Chimera
- Amino Acids
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- K562 Cells
- Ubiquitins
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Affiliation(s)
- Jianchao Zhang
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Caibing Ma
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong, China
| | - Yongjun Yu
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Chaowei Liu
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen, China
| | - Lijing Fang
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong, China.
| | - Hai Rao
- Department of Biochemistry, School of Medicine, Southern University of Science and Technology, Shenzhen, China; Key University Laboratory of Metabolism and Health of Guangdong, Southern University of Science and Technology, Shenzhen, China.
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8
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Sun S, Qin J, Liao W, Gao X, Shang Z, Luo D, Xiong S. Mitochondrial Dysfunction in Cardiotoxicity Induced by BCR-ABL1 Tyrosine Kinase Inhibitors -Underlying Mechanisms, Detection, Potential Therapies. Cardiovasc Toxicol 2023; 23:233-254. [PMID: 37479951 DOI: 10.1007/s12012-023-09800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/08/2023] [Indexed: 07/23/2023]
Abstract
The advent of BCR-ABL tyrosine kinase inhibitors (TKIs) targeted therapy revolutionized the treatment of chronic myeloid leukemia (CML) patients. Mitochondria are the key organelles for the maintenance of myocardial tissue homeostasis. However, cardiotoxicity associated with BCR-ABL1 TKIs can directly or indirectly cause mitochondrial damage and dysfunction, playing a pivotal role in cardiomyocytes homeostatic system and putting the cancer survivors at higher risk. In this review, we summarize the cardiotoxicity caused by BCR-ABL1 TKIs and the underlying mechanisms, which contribute dominantly to the damage of mitochondrial structure and dysfunction: endoplasmic reticulum (ER) stress, mitochondrial stress, damage of myocardial cell mitochondrial respiratory chain, increased production of mitochondrial reactive oxygen species (ROS), and other kinases and other potential mechanisms of cardiotoxicity induced by BCR-ABL1 TKIs. Furthermore, detection and management of BCR-ABL1 TKIs will promote our rational use, and cardioprotection strategies based on mitochondria will improve our understanding of the cardiotoxicity from a mitochondrial perspective. Ultimately, we hope shed light on clinical decision-making. By integrate and learn from both research and practice, we will endeavor to minimize the mitochondria-mediated cardiotoxicity and reduce the adverse sequelae associated with BCR-ABL1 TKIs.
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Affiliation(s)
- Sheng Sun
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Department of Medical Oncology, Hospital of Chengdu University of Traditioanal Chinese Medicine, Chengdu, 610075, Sichuan Province, China
| | - Jiqiu Qin
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wenhao Liao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiang Gao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhoubiao Shang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dehua Luo
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shaoquan Xiong
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
- Department of Medical Oncology, Hospital of Chengdu University of Traditioanal Chinese Medicine, Chengdu, 610075, Sichuan Province, China.
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9
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Iurlo A, Cattaneo D, Consonni D, Castagnetti F, Miggiano MC, Binotto G, Bonifacio M, Rege-Cambrin G, Tiribelli M, Lunghi F, Gozzini A, Pregno P, Abruzzese E, Capodanno I, Bucelli C, Pizzuti M, Artuso S, Iezza M, Scalzulli E, La Barba G, Maggi A, Russo S, Elena C, Scortechini AR, Tafuri A, Latagliata R, Caocci G, Bocchia M, Galimberti S, Luciano L, Fava C, Foà R, Saglio G, Rosti G, Breccia M. Treatment discontinuation following low-dose TKIs in 248 chronic myeloid leukemia patients: Updated results from a campus CML real-life study. Front Pharmacol 2023; 14:1154377. [PMID: 37033642 PMCID: PMC10076530 DOI: 10.3389/fphar.2023.1154377] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
TKIs long-term treatment in CML may lead to persistent adverse events (AEs) that can promote relevant morbidity and mortality. Consequently, TKIs dose reduction is often used to prevent AEs. However, data on its impact on successful treatment-free remission (TFR) are quite scarce. We conducted a retrospective study on the outcome of CML subjects who discontinued low-dose TKIs from 54 Italian hematology centers participating in the Campus CML network. Overall, 1.785 of 5.108 (35.0%) regularly followed CML patients were treated with low-dose TKIs, more frequently due to relevant comorbidities or AEs (1.288, 72.2%). TFR was attempted in 248 (13.9%) subjects, all but three while in deep molecular response (DMR). After a median follow-up of 24.9 months, 172 (69.4%) patients were still in TFR. TFR outcome was not influenced by gender, Sokal/ELTS risk scores, prior interferon, number and last type of TKI used prior to treatment cessation, DMR degree, reason for dose reduction or median TKIs duration. Conversely, TFR probability was significantly better in the absence of resistance to any prior TKI. In addition, patients with a longer DMR duration before TKI discontinuation (i.e., >6.8 years) and those with an e14a2 BCR::ABL1 transcript type showed a trend towards prolonged TFR. It should also be emphasized that only 30.6% of our cases suffered from molecular relapse, less than reported during full-dose TKI treatment. The use of low-dose TKIs does not appear to affect the likelihood of achieving a DMR and thus trying a treatment withdrawal, but might even promote the TFR rate.
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Affiliation(s)
- A. Iurlo
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: A. Iurlo,
| | - D. Cattaneo
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - D. Consonni
- Epidemiology Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F. Castagnetti
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. and A. Seràgnoli”, University of Bologna, “S. Orsola-Malpighi” Hospital, Bologna, Italy
| | - M. C. Miggiano
- Division of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - G. Binotto
- Department of Medicine, Hematology and Clinical Immunology, Padua School of Medicine, Padua, Italy
| | - M. Bonifacio
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - G. Rege-Cambrin
- Division of Internal Medicine and Hematology, San Luigi Gonzaga Hospital, Turin, Italy
| | - M. Tiribelli
- Division of Hematology and BMT—Udine Hopsital, ASUFC and Department of Medicine—University of Udine, Udine, Italy
| | - F. Lunghi
- Division of Hematology and BMT, IRCCS San Raffaele Hospital, Milan, Italy
| | - A. Gozzini
- Division of Hematology, AOU Careggi, Firenze, Italy
| | - P. Pregno
- Division of Hematology, AOU Città della Salute e della Scienza, Torino, Italy
| | - E. Abruzzese
- Hematology Division, Sant’Eugenio Hospital, Rome, Italy
| | - I. Capodanno
- Division of Hematology, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - C. Bucelli
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M. Pizzuti
- Hematology Unit, Ospedale Potenza, Potenza, Italy
| | - S. Artuso
- Hematology Division, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M. Iezza
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology “L. and A. Seràgnoli”, University of Bologna, “S. Orsola-Malpighi” Hospital, Bologna, Italy
| | - E. Scalzulli
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - G. La Barba
- Hematology Unit, Azienda USL di Pescara, Pescara, Italy
| | - A. Maggi
- Division of Hematology, Hospital “S. G. Moscati”, Taranto, Italy
| | - S. Russo
- Division of Hematology, Dipartimento di Patologia Umana dell''Adulto e dell'Età Evolutiva, Policlinico G. Martino, University of Messina, Messina, Italy
| | - C. Elena
- UOC Ematologia 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - A. R. Scortechini
- Division of Hematology, Department of Molecular and Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - A. Tafuri
- Division of Hematology, Azienda Ospedaliera Universitaria Sant'Andrea, Rome, Italy
| | - R. Latagliata
- Division of Hematology, Belcolle Hospital, Viterbo, Italy
| | - G. Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Businco Hospital, Cagliari, Italy
| | - M. Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - S. Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - L. Luciano
- Division of Hematology, Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - C. Fava
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - R. Foà
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - G. Saglio
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - G. Rosti
- Scientific Direction, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - M. Breccia
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
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10
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Therapy Resistance and Disease Progression in CML: Mechanistic Links and Therapeutic Strategies. Curr Hematol Malig Rep 2022; 17:181-197. [PMID: 36258106 DOI: 10.1007/s11899-022-00679-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Despite the adoption of tyrosine kinases inhibitors (TKIs) as molecular targeted therapy in chronic myeloid leukemia, some patients do not respond to treatment and even experience disease progression. This review aims to give a broad summary of advances in understanding of the mechanisms of therapy resistance, as well as management strategies that may overcome or prevent the emergence of drug resistance. Ultimately, the goal of therapy is the cure of CML, which will also require an increased understanding of the leukemia stem cell (LSC). RECENT FINDINGS Resistance to tyrosine kinase inhibitors stems from a range of possible causes. Mutations of the BCR-ABL1 fusion oncoprotein have been well-studied. Other causes range from cell-intrinsic factors, such as the inherent resistance of primitive stem cells to drug treatment, to mechanisms extrinsic to the leukemic compartment that help CML cells evade apoptosis. There exists heterogeneity in TKI response among different hematopoietic populations in CML. The abundances of these TKI-sensitive and TKI-insensitive populations differ from patient to patient and contribute to response heterogeneity. It is becoming clear that targeting the BCR-ABL1 kinase through TKIs is only one part of the equation, and TKI usage alone may not cure the majority of patients with CML. Considerable effort should be devoted to targeting the BCR-ABL1-independent mechanisms of resistance and persistence of CML LSCs.
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11
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Identification of key microRNAs as predictive biomarkers of Nilotinib response in chronic myeloid leukemia: a sub-analysis of the ENESTxtnd clinical trial. Leukemia 2022; 36:2443-2452. [PMID: 35999259 DOI: 10.1038/s41375-022-01680-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 11/08/2022]
Abstract
Despite the effectiveness of tyrosine kinase inhibitors (TKIs) against chronic myeloid leukemia (CML), they are not usually curative as some patients develop drug-resistance or are at risk of disease relapse when treatment is discontinued. Studies have demonstrated that primitive CML cells display unique miRNA profiles in response to TKI treatment. However, the utility of miRNAs in predicting treatment response is not yet conclusive. Here, we analyzed differentially expressed miRNAs in CD34+ CML cells pre- and post-nilotinib (NL) therapy from 58 patients enrolled in the Canadian sub-analysis of the ENESTxtnd phase IIIb clinical trial which correlated with sensitivity of CD34+ cells to NL treatment in in vitro colony-forming cell (CFC) assays. We performed Cox Proportional Hazard (CoxPH) analysis and applied machine learning algorithms to generate multivariate miRNA panels which can predict NL response at treatment-naïve or post-treatment time points. We demonstrated that a combination of miR-145 and miR-708 are effective predictors of NL response in treatment-naïve patients whereas miR-150 and miR-185 were significant classifiers at 1-month and 3-month post-NL therapy. Interestingly, incorporation of NL-CFC output in these panels enhanced predictive performance. Thus, this novel predictive model may be developed into a prognostic tool for use in the clinic.
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12
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Poudel G, Tolland MG, Hughes TP, Pagani IS. Mechanisms of Resistance and Implications for Treatment Strategies in Chronic Myeloid Leukaemia. Cancers (Basel) 2022; 14:cancers14143300. [PMID: 35884363 PMCID: PMC9317051 DOI: 10.3390/cancers14143300] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 12/01/2022] Open
Abstract
Simple Summary Chronic myeloid leukaemia (CML) is a type of blood cancer that is currently well-managed with drugs that target cancer-causing proteins. However, a significant proportion of CML patients do not respond to those drug treatments or relapse when they stop those drugs because the cancer cells in those patients stop relying on that protein and instead develop a new way to survive. Therefore, new treatment strategies may be necessary for those patients. In this review, we discuss those additional survival pathways and outline combination treatment strategies to increase responses and clinical outcomes, improving the lives of CML patients. Abstract Tyrosine kinase inhibitors (TKIs) have revolutionised the management of chronic myeloid leukaemia (CML), with the disease now having a five-year survival rate over 80%. The primary focus in the treatment of CML has been on improving the specificity and potency of TKIs to inhibit the activation of the BCR::ABL1 kinase and/or overcoming resistance driven by mutations in the BCR::ABL1 oncogene. However, this approach may be limited in a significant proportion of patients who develop TKI resistance despite the effective inhibition of BCR::ABL1. These patients may require novel therapeutic strategies that target both BCR::ABL1-dependent and BCR::ABL1-independent mechanisms of resistance. The combination treatment strategies that target alternative survival signalling, which may contribute towards BCR::ABL1-independent resistance, could be a successful strategy for eradicating residual leukaemic cells and consequently increasing the response rate in CML patients.
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Affiliation(s)
- Govinda Poudel
- Cancer Program, Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia; (G.P.); (M.G.T.); (T.P.H.)
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5000, Australia
- Australasian Leukaemia and Lymphoma Group, Richmond, VIC 3121, Australia
| | - Molly G. Tolland
- Cancer Program, Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia; (G.P.); (M.G.T.); (T.P.H.)
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5000, Australia
| | - Timothy P. Hughes
- Cancer Program, Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia; (G.P.); (M.G.T.); (T.P.H.)
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5000, Australia
- Australasian Leukaemia and Lymphoma Group, Richmond, VIC 3121, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital and SA Pathology, Adelaide, SA 5000, Australia
| | - Ilaria S. Pagani
- Cancer Program, Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia; (G.P.); (M.G.T.); (T.P.H.)
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5000, Australia
- Australasian Leukaemia and Lymphoma Group, Richmond, VIC 3121, Australia
- Correspondence:
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13
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Lu L, Kok CH, Dang P, Branford S, Saunders VA, Shanmuganathan N, Ross DM, Hughes TP, Yeung DTO. Highly sensitive droplet digital polymerase chain reaction for BCR::ABL1 messenger RNA identifies patients with chronic myeloid leukaemia with a low probability of achieving treatment-free remission. Br J Haematol 2022; 198:600-603. [PMID: 35620965 DOI: 10.1111/bjh.18277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Liu Lu
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Chung Hoow Kok
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Phuong Dang
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia
| | - Susan Branford
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Genetics and Molecular Pathology & Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
| | - Verity A Saunders
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia
| | - Naranie Shanmuganathan
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Genetics and Molecular Pathology & Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia.,Department of Haematology, SA Pathology, Adelaide, South Australia, Australia
| | - David M Ross
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Genetics and Molecular Pathology & Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,Department of Haematology, SA Pathology, Adelaide, South Australia, Australia
| | - Timothy P Hughes
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Haematology, SA Pathology, Adelaide, South Australia, Australia
| | - David T O Yeung
- South Australian Health and Medical Research Institute (SAHMRI), Precision Medicine Cancer Theme, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Genetics and Molecular Pathology & Centre for Cancer Biology, SA Pathology, Adelaide, Australia.,Department of Haematology, SA Pathology, Adelaide, South Australia, Australia
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14
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Pagani IS, Poudel G, Wardill HR. A Gut Instinct on Leukaemia: A New Mechanistic Hypothesis for Microbiota-Immune Crosstalk in Disease Progression and Relapse. Microorganisms 2022; 10:microorganisms10040713. [PMID: 35456764 PMCID: PMC9029211 DOI: 10.3390/microorganisms10040713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/15/2022] [Accepted: 03/23/2022] [Indexed: 02/05/2023] Open
Abstract
Despite significant advances in the treatment of Chronic Myeloid and Acute Lymphoblastic Leukaemia (CML and ALL, respectively), disease progression and relapse remain a major problem. Growing evidence indicates the loss of immune surveillance of residual leukaemic cells as one of the main contributors to disease recurrence and relapse. More recently, there was an appreciation for how the host’s gut microbiota predisposes to relapse given its potent immunomodulatory capacity. This is especially compelling in haematological malignancies where changes in the gut microbiota have been identified after treatment, persisting in some patients for years after the completion of treatment. In this hypothesis-generating review, we discuss the interaction between the gut microbiota and treatment responses, and its capacity to influence the risk of relapse in both CML and ALL We hypothesize that the gut microbiota contributes to the creation of an immunosuppressive microenvironment, which promotes tumour progression and relapse.
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Affiliation(s)
- Ilaria S. Pagani
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide 5000, Australia; (G.P.); (H.R.W.)
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide 5000, Australia
- Correspondence:
| | - Govinda Poudel
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide 5000, Australia; (G.P.); (H.R.W.)
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Hannah R. Wardill
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide 5000, Australia; (G.P.); (H.R.W.)
- Faculty of Health and Medical Sciences, School of Biomedicine, University of Adelaide, Adelaide 5000, Australia
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15
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Iurlo A, Cattaneo D, Artuso S, Consonni D, Abruzzese E, Binotto G, Bocchia M, Bonifacio M, Castagnetti F, Galimberti S, Gozzini A, Iezza M, Latagliata R, Luciano L, Maggi A, Miggiano MC, Pregno P, Rege-Cambrin G, Russo S, Scortechini AR, Tafuri A, Tiribelli M, Fava C, Rosti G, Foa R, Breccia M, Saglio G. Treatment-Free Remission in Chronic Myeloid Leukemia Patients Treated With Low-Dose TKIs: A Feasible Option Also in the Real-Life. A Campus CML Study. Front Oncol 2022; 12:839915. [PMID: 35311109 PMCID: PMC8927081 DOI: 10.3389/fonc.2022.839915] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/14/2022] [Indexed: 01/06/2023] Open
Abstract
Treatment-free remission (TFR) has become a primary therapeutic goal in CML and is also considered feasible by international guidelines. TKIs dose reduction is often used in real-life practice to reduce adverse events, although its impact on TFR is still a matter of debate. This study aimed to explore the attitude of Italian hematologists towards prescribing TKIs at reduced doses and its impact on TFR. In September 2020, a questionnaire was sent to 54 hematology centers in Italy participating to the Campus CML network. For each patient, data on the main disease characteristics were collected. Most of the hematologists involved (64.4%) believed that low-dose TKIs should not influence TFR. Indeed, this approach was offered to 194 patients. At the time of TFR, all but 3 patients had already achieved a DMR, with a median duration of 61.0 months. After a median follow-up of 29.2 months, 138 (71.1%) patients were still in TFR. Interestingly, TFR outcome was not impaired by any of the variables examined, including sex, risk scores, BCR-ABL1 transcript types, previous interferon, type and number of TKIs used before treatment cessation, degree of DMR or median duration of TKIs therapy. On the contrary, TFR was significantly better after dose reduction due to AEs; furthermore, patients with a longer DMR duration showed a trend towards prolonged TFR. This survey indicates that low-dose TKI treatment is an important reality. While one third of Italian hematologists still had some uncertainties on TFR feasibility after using reduced doses of TKIs outside of clinical trials, TFR has often been considered a safe option even in patients treated with low-dose TKIs in the real-life setting. It should be noted that only 28.9% of our cases had a molecular recurrence, less than reported during standard dose treatment. Consequently, TFR is not impaired using low-dose TKIs.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Silvia Artuso
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Gianni Binotto
- Department of Medicine, Hematology and Clinical Immunology, Padua School of Medicine, Padua, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Fausto Castagnetti
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, "S. Orsola-Malpighi" Hospital, Bologna, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Miriam Iezza
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, "S. Orsola-Malpighi" Hospital, Bologna, Italy
| | | | - Luigiana Luciano
- Division of Hematology, Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | | | | | - Patrizia Pregno
- Division of Hematology, AOU Città della Salute e della Scienza, Torino, Italy
| | - Giovanna Rege-Cambrin
- Division of Internal Medicine and Hematology, San Luigi Gonzaga Hospital, Turin, Italy
| | - Sabina Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Anna Rita Scortechini
- Division of Hematology, Department of Molecular and Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Agostino Tafuri
- Division of Hematology, Azienda Ospedaliera Universitaria Sant'Andrea, Rome, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medical and Morphological Research, University of Udine, Udine, Italy
| | - Carmen Fava
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Gianantonio Rosti
- Scientific Direction, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Robin Foa
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
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16
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Stuckey R, López Rodríguez JF, Gómez-Casares MT. Discontinuation of Tyrosine Kinase Inhibitors in Patients with Chronic Myeloid Leukemia: a Review of the Biological Factors Associated with Treatment-Free Remission. Curr Oncol Rep 2022; 24:415-426. [PMID: 35141859 PMCID: PMC8930955 DOI: 10.1007/s11912-022-01228-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Purpose of Review Clinical factors alone do not enable us to differentiate which patients will maintain treatment-free remission (TFR) from those who are likely to relapse. Thus, patient-specific factors must also play a role. This review will update the reader on the most recent studies presenting biological factors that can help predict tyrosine kinase inhibitor (TKI) discontinuation success. Recent Findings Cellular and molecular factors with a suggested role in TFR include immune factors and leukemic stem cell (LSC) persistence; the BCR::ABL1 transcript type, halving time, and BCR::ABL1 DNA and RNA positivity; as well as other molecular factors such as somatic mutations, RNA expression, and telomere length. Summary Our review presents several biomarkers with predictive value for TFR but also highlights areas of unmet need. Future discontinuation guidelines will likely include biological factors for the personalization of TFR prediction. However, it will be important that such advances do not prevent more patients from making a TKI discontinuation attempt.
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Affiliation(s)
- Ruth Stuckey
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, Las Palmas, Spain.
| | | | - María Teresa Gómez-Casares
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, Las Palmas, Spain
- Medical Science Department, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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17
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Hochhaus A. TKI discontinuation in CML: how do we make more patients eligible? How do we increase the chances of a successful treatment-free remission? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:106-112. [PMID: 34889388 PMCID: PMC8791110 DOI: 10.1182/hematology.2021000238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Treatment-free remission (TFR) is a new and significant goal of chronic myeloid leukemia management. TFR should be considered for patients in stable deep molecular response (DMR) after careful discussion in the shared decision-making process. Second-generation tyrosine kinase inhibitors (TKIs) improve the speed of response and the incidence of DMR. Treatment may be changed to a more active TKI to improve the depth of response in selected patients who have not reached DMR. Stem cell persistence is associated with active immune surveillance and activation of BCR-ABL1-independent pathways, eg, STAT3, JAK1/2, and BCL2. Ongoing studies aim to prove the efficacy of maintenance therapies targeting these pathways after TKI discontinuation.
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Affiliation(s)
- Andreas Hochhaus
- Correspondence Andreas Hochhaus, Klinik für Innere Medizin II, Universitätsklinikum Jena, Am Klinikum 1, 07740 Jena, Germany; e-mail:
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18
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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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19
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Krishnan V, Kim DDH, Hughes TP, Branford S, Ong ST. Integrating genetic and epigenetic factors in chronic myeloid leukemia risk assessment: toward gene expression-based biomarkers. Haematologica 2021; 107:358-370. [PMID: 34615339 PMCID: PMC8804571 DOI: 10.3324/haematol.2021.279317] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Indexed: 11/17/2022] Open
Abstract
Cancer treatment is constantly evolving from a one-size-fits-all towards bespoke approaches for each patient. In certain solid cancers, including breast and lung, tumor genome profiling has been incorporated into therapeutic decision-making. For chronic phase chronic myeloid leukemia (CML), while tyrosine kinase inhibitor therapy is the standard treatment, current clinical scoring systems cannot accurately predict the heterogeneous treatment outcomes observed in patients. Biomarkers capable of segregating patients according to outcome at diagnosis are needed to improve management, and facilitate enrollment in clinical trials seeking to prevent blast crisis transformation and improve the depth of molecular responses. To this end, gene expression (GE) profiling studies have evaluated whether GE signatures at diagnosis are clinically informative. Patient material from a variety of sources has been profiled using microarrays, RNA sequencing and, more recently, single-cell RNA sequencing. However, differences in the cell types profiled, the technologies used, and the inherent complexities associated with the interpretation of genomic data pose challenges in distilling GE datasets into biomarkers with clinical utility. The goal of this paper is to review previous studies evaluating GE profiling in CML, and explore their potential as risk assessment tools for individualized CML treatment. We also review the contribution that acquired mutations, including those seen in clonal hematopoiesis, make to GE profiles, and how a model integrating contributions of genetic and epigenetic factors in resistance to tyrosine kinase inhibitors and blast crisis transformation can define a route to GE-based biomarkers. Finally, we outline a four-stage approach for the development of GE-based biomarkers in CML.
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Affiliation(s)
- Vaidehi Krishnan
- Cancer and Stem Cell Biology Signature Research Program, Duke-NUS Medical School, Singapore, Singapore; International Chronic Myeloid Leukemia Foundation
| | - Dennis Dong Hwan Kim
- International Chronic Myeloid Leukemia Foundation; Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto
| | - Timothy P Hughes
- International Chronic Myeloid Leukemia Foundation; School of Medicine, University of Adelaide, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; Department of Haematology, Royal Adelaide Hospital, Adelaide
| | - Susan Branford
- International Chronic Myeloid Leukemia Foundation; School of Medicine, University of Adelaide, Adelaide, Australia; Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology, Adelaide, Australia; School of Pharmacy and Medical Science, University of South Australia, Adelaide
| | - S Tiong Ong
- Cancer and Stem Cell Biology Signature Research Program, Duke-NUS Medical School, Singapore, Singapore; International Chronic Myeloid Leukemia Foundation; Department of Haematology, Singapore General Hospital, Singapore, Singapore; Department of Medical Oncology, National Cancer Centre Singapore; Department of Medicine, Duke University Medical Center, Durham, NC.
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20
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Compromised anti-tumor-immune features of myeloid cell components in chronic myeloid leukemia patients. Sci Rep 2021; 11:18046. [PMID: 34508131 PMCID: PMC8433374 DOI: 10.1038/s41598-021-97371-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/24/2021] [Indexed: 11/08/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a form of myeloproliferative neoplasm caused by the oncogenic tyrosine kinase BCR-ABL. Although tyrosine kinase inhibitors have dramatically improved the prognosis of patients with CML, several problems such as resistance and recurrence still exist. Immunological control may contribute to solving these problems, and it is important to understand why CML patients fail to spontaneously develop anti-tumor immunity. Here, we show that differentiation of conventional dendritic cells (cDCs), which are vital for anti-tumor immunity, is restricted from an early stage of hematopoiesis in CML. In addition, we found that monocytes and basophils, which are increased in CML patients, express high levels of PD-L1, an immune checkpoint molecule that inhibits T cell responses. Moreover, RNA-sequencing analysis revealed that basophils express genes related to poor prognosis in CML. Our data suggest that BCR-ABL not only disrupts the “accelerator” (i.e., cDCs) but also applies the “brake” (i.e., monocytes and basophils) of anti-tumor immunity, compromising the defense against CML cells.
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21
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Lei H, Wang J, Hu J, Zhu Q, Wu Y. Deubiquitinases in hematological malignancies. Biomark Res 2021; 9:66. [PMID: 34454635 PMCID: PMC8401176 DOI: 10.1186/s40364-021-00320-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/06/2021] [Indexed: 12/18/2022] Open
Abstract
Deubiquitinases (DUBs) are enzymes that control the stability, interactions or localization of most cellular proteins by removing their ubiquitin modification. In recent years, some DUBs, such as USP7, USP9X and USP10, have been identified as promising therapeutic targets in hematological malignancies. Importantly, some potent inhibitors targeting the oncogenic DUBs have been developed, showing promising inhibitory efficacy in preclinical models, and some have even undergone clinical trials. Different DUBs perform distinct function in diverse hematological malignancies, such as oncogenic, tumor suppressor or context-dependent effects. Therefore, exploring the biological roles of DUBs and their downstream effectors will provide new insights and therapeutic targets for the occurrence and development of hematological malignancies. We summarize the DUBs involved in different categories of hematological malignancies including leukemia, multiple myeloma and lymphoma. We also present the recent development of DUB inhibitors and their applications in hematological malignancies. Together, we demonstrate DUBs as potential therapeutic drug targets in hematological malignancies.
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Affiliation(s)
- Hu Lei
- Department of Pathophysiology, International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Jiaqi Wang
- Department of Pathophysiology, International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jiacheng Hu
- Department of Pathophysiology, International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qian Zhu
- Department of Pathophysiology, International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yingli Wu
- Department of Pathophysiology, International Institute of Medicine, Shanghai Tongren Hospital/Faculty of Basic Medicine, Key Laboratory of Cell Differentiation and Apoptosis of the Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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22
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Saifullah HH, Lucas CM. Treatment-Free Remission in Chronic Myeloid Leukemia: Can We Identify Prognostic Factors? Cancers (Basel) 2021; 13:cancers13164175. [PMID: 34439327 PMCID: PMC8392063 DOI: 10.3390/cancers13164175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Chronic myeloid leukemia (CML) is a blood cancer. Unlike other cancers CML treatment is lifelong and many patients experience side effects. For those patients who respond well to treatment and achieve deep molecular remission, quality of life is impacted because of continuous treatment. In this review, we look at emerging clinical trials which aim to investigate which patients can safely stop treatment. Treatment-free remission is the ultimate goal for CML patients, but there is still a gap in our knowledge as to why some patients can achieve treatment-free remission, while others relapse when treatment is stopped. Here we discuss if there are any prognostic factors that can predict the best candidates who qualify for treatment discontinuation, with a view to keeping them in remission. Abstract Following the development of tyrosine kinase inhibitors (TKI), the survival of patients with chronic myeloid leukaemia (CML) drastically improved. With the introduction of these agents, CML is now considered a chronic disease for some patients. Taking into consideration the side effects, toxicity, and high cost, discontinuing TKI became a goal for patients with chronic phase CML. Patients who achieved deep molecular response (DMR) and discontinued TKI, remained in treatment-free remission (TFR). Currently, the data from the published literature demonstrate that 40–60% of patients achieve TFR, with relapses occurring within the first six months. In addition, almost all patients who relapsed regained a molecular response upon retreatment, indicating TKI discontinuation is safe. However, there is still a gap in understanding the mechanisms behind TFR, and whether there are prognostic factors that can predict the best candidates who qualify for TKI discontinuation with a view to keeping them in TFR. Furthermore, the information about a second TFR attempt and the role of gradual de-escalation of TKI before complete cessation is limited. This review highlights the factors predicting success or failure of TFR. In addition, it examines the feasibility of a second TFR attempt after the failure of the first one, and the current guidelines concerning TFR in clinical practice.
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Affiliation(s)
- Hilbeen Hisham Saifullah
- Chester Medical School, University of Chester, Bache Hall, Chester CH2 1BR, UK
- Correspondence: (H.H.S.); (C.M.L.)
| | - Claire Marie Lucas
- Chester Medical School, University of Chester, Bache Hall, Chester CH2 1BR, UK
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool L69 3GA, UK
- Correspondence: (H.H.S.); (C.M.L.)
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23
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Ma CE, Ghosh S, Leyshon C, Blosser N, Dersch-Mills D, Jupp J, Savoie L, Liew E, Jamani K. Clinical outcome of chronic myeloid leukemia patients who switch from first-line therapy with a second generation tyrosine kinase inhibitor to an alternative TKI. Leuk Res 2021; 111:106674. [PMID: 34333277 DOI: 10.1016/j.leukres.2021.106674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
While second generation tyrosine kinase inhibitors (2GTKIs) are highly effective therapies for chronic myeloid leukemia (CML), a significant minority of patients who initiate a 2GTKI will require a switch to an alternative TKI. The long-term outcomes of those who require a change in therapy after front-line 2GTKI therapy are largely undescribed. Here we describe the clinical outcomes associated with switch to an alternative TKI after first-line therapy with a 2GTKI. Of 232 patients who initiated a 2GTKI during the study period, 76 (33 %) switched to an alternative TKI. Reasons for switching included intolerance (79 %) and resistance (21 %). Among the 60 patients who switched due to intolerance, 53 (88 %) were able to achieve or maintain a major molecular response (MMR) with 5-year progression-free survival (PFS) 90.5 % (95 % CI 90.4-90.6 %). Amongst the 16 patients who switched due to resistance, 8 patients (50 %) were able to achieve MMR with 5-year PFS 80.4 % (95 % CI 80.2-80.6 %). Most patients who switched due to intolerance remained on their second-line TKI. Approximately 25 % of patients who initiate first-line 2GTKI in a real world setting will ultimately switch to an alternate TKI due to intolerance. Patients who switch for intolerance continue to enjoy excellent clinical outcomes.
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Affiliation(s)
- Chen-En Ma
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, 11560 University Ave., Edmonton, Alberta, T6G 1Z2, Canada
| | - Catherine Leyshon
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada
| | - Nikki Blosser
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada
| | - Deonne Dersch-Mills
- Alberta Children's Hospital, 28 Oki Drive NW, Calgary, Alberta, T3B 6A8, Canada
| | - Jennifer Jupp
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada; Alberta Children's Hospital, 28 Oki Drive NW, Calgary, Alberta, T3B 6A8, Canada
| | - Lynn Savoie
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada
| | - Elena Liew
- Cross Cancer Institute, 11560 University Ave., Edmonton, Alberta, T6G 1Z2, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre, 1331 29 St. NW, Calgary, Alberta, T2N 4N2, Canada.
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24
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Soverini S, De Santis S, Monaldi C, Bruno S, Mancini M. Targeting Leukemic Stem Cells in Chronic Myeloid Leukemia: Is It Worth the Effort? Int J Mol Sci 2021; 22:ijms22137093. [PMID: 34209376 PMCID: PMC8269304 DOI: 10.3390/ijms22137093] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic myeloid leukemia (CML) is a classical example of stem cell cancer since it arises in a multipotent hematopoietic stem cell upon the acquisition of the t(9;22) chromosomal translocation, that converts it into a leukemic stem cell (LSC). The resulting BCR-ABL1 fusion gene encodes a deregulated tyrosine kinase that is recognized as the disease driver. Therapy with tyrosine kinase inhibitors (TKIs) eliminates progenitor and more differentiated cells but fails to eradicate quiescent LSCs. Thus, although many patients obtain excellent responses and a proportion of them can even attempt treatment discontinuation (treatment free remission [TFR]) after some years of therapy, LSCs persist, and represent a potentially dangerous reservoir feeding relapse and hampering TFR. Over the past two decades, intensive efforts have been devoted to the characterization of CML LSCs and to the dissection of the cell-intrinsic and -extrinsic mechanisms sustaining their persistence, in an attempt to find druggable targets enabling LSC eradication. Here we provide an overview and an update on these mechanisms, focusing in particular on the most recent acquisitions. Moreover, we provide a critical appraisal of the clinical relevance and feasibility of LSC targeting in CML.
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MESH Headings
- Drug Delivery Systems
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Neoplastic Stem Cells/enzymology
- Protein Kinase Inhibitors/therapeutic use
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Affiliation(s)
- Simona Soverini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, 40138 Bologna, Italy; (S.D.S.); (C.M.); (S.B.)
- Correspondence: ; Tel.: +39-051-214-3832
| | - Sara De Santis
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, 40138 Bologna, Italy; (S.D.S.); (C.M.); (S.B.)
| | - Cecilia Monaldi
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, 40138 Bologna, Italy; (S.D.S.); (C.M.); (S.B.)
| | - Samantha Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, 40138 Bologna, Italy; (S.D.S.); (C.M.); (S.B.)
| | - Manuela Mancini
- Istituto di Ematologia “Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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25
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Ross DM. How much imatinib is enough? Br J Haematol 2021; 193:699-700. [PMID: 33876424 DOI: 10.1111/bjh.17444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David M Ross
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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26
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Cerveira N, Bizarro S, Teixeira MR, Mariz JM. When to Stop TKIs in Patients with Chronic Myeloid Leukemia and How to Follow Them Subsequently. Curr Treat Options Oncol 2021; 22:49. [PMID: 33866455 DOI: 10.1007/s11864-021-00851-2] [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: 03/16/2021] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT ABL1 tyrosine kinase inhibitors (TKI) have dramatically improved the outcome for CML (chronic myeloid leukemia) patients. When TKI therapy is addressed appropriately, it can lead to an optimal molecular response in the majority of CML patients and a life expectancy that approaches that of the general population. However, lifelong TKI therapy may have consequences, including chronic, mostly low-grade, adverse events that can substantially impact patients' quality of life, adherence to therapy and, consequently, success of treatment. In the last few years, several groups have demonstrated that approximately 50% of chronic phase CML patients (CP-CML) who have achieved a stable deep molecular response (DMR) can stop therapy without suffering molecular relapse. Nowadays, treatment-free remission (TFR) has a significant role in the management of CML and should be considered in selected motivated patients that fulfill well-defined requirements to maximize the probability of successful discontinuation of TKI therapy.
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Affiliation(s)
- Nuno Cerveira
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.
| | - Susana Bizarro
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Manuel R Teixeira
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.,Instituto de Ciências Biomédicas, Universidade do Porto, Porto, Portugal
| | - José M Mariz
- Serviço de Hematologia, Instituto Português de Oncologia do Porto, Porto, Portugal
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27
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Pepe S, Scalzulli E, Colafigli G, Di Prima A, Mancini M, Diverio D, Latagliata R, Martelli M, Foà R, Breccia M. Long-term follow-up of late chronic phase chronic myeloid leukemia patients treated with imatinib after interferon failure: a single center experience. Leuk Lymphoma 2021; 62:2261-2266. [PMID: 33722147 DOI: 10.1080/10428194.2021.1901094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We report the long-term outcome of 139 patients treated with imatinib in late chronic phase after IFN failure. Median follow-up was 16.6 years and the estimated 18-year OS was 64.8%. 18-year EFS and PFS were 69% and 64.4%, respectively. Fifty (36%) patients stopped imatinib, 72% received a second line. b2a2 transcript was associated with a significantly inferior 18-year OS (p = 0.008), FFS (p = 0.036), PFS (p = 0.013) compared to the b3a2 type, whilst the type of transcript did not influence the time to response achievement. Failure to achieve MMR at 12 months significantly reduced the chance of reaching a DMR (p = 0.001). Imatinib discontinuation after achieving a sustained deep molecular response was attempted in 14 patients; 12 (86%) are still in treatment-free remission (TFR) at the last follow-up. Our experience confirms the long-term efficacy of imatinib after IFNα failure in real-life setting and documents the possibility of attempting a TFR in this subset of patients.
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Affiliation(s)
- Sara Pepe
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Gioia Colafigli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Alessio Di Prima
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Marco Mancini
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Daniela Diverio
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Roberto Latagliata
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University, Rome, Italy
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28
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Dose Optimization of Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A New Therapeutic Challenge. J Clin Med 2021; 10:jcm10030515. [PMID: 33535564 PMCID: PMC7867069 DOI: 10.3390/jcm10030515] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/18/2022] Open
Abstract
The chronic myeloid leukemia (CML) therapeutic landscape has dramatically changed with tyrosine kinase inhibitor (TKI) development, which allows a near-normal life expectancy. However, long-term TKI exposure has been associated with persistent adverse events (AEs) which negatively impact on quality of life (QoL) and have the potential to cause significant morbidity and mortality. In clinical practice, TKI dose reduction is usually considered to reduce AEs and improve QoL, but dose optimization could have also another aim, i.e., the achievement and maintenance of cytogenetic and molecular responses. While therapy cessation appeared as a safe option for about half of the patients achieving an optimal response, no systematic assessment of long-term TKI dose de-escalation has been made. The present review is focused on the most recent evidences for TKIs dose modifications in CML clinical studies and in the real-life setting. It will consider TKI dose modifications in newly diagnosed patients, dose reduction for AEs, or in deep molecular response, either as a prelude to treatment-free remission (TFR) or as continuous maintenance therapy in those patients not wishing to attempt TFR. In addition, it will focus on patients not achieving a molecular response deep enough to go to TFR, and for whom dose reduction could be an option to avoid AEs.
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Ross DM, Hughes TP. Counterpoint: There is a best duration of deep molecular response for treatment-free remission, but it is patient-specific, and that is the challenge. Br J Haematol 2020; 192:24-27. [PMID: 33169882 DOI: 10.1111/bjh.17111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/25/2020] [Indexed: 12/18/2022]
Abstract
There is considerable clinical and scientific interest in identifying reliable predictors of treatment-free remission in chronic myeloid leukaemia. Most predictors have been identified from non-randomized clinical trials or retrospective cohorts that could be subject to bias. The validity of predictive factors, such as duration of treatment or of deep molecular response, has been questioned. We briefly review the relevant data and the potential for bias, arguing that the risk of bias may be overstated, and that accumulating data strongly suggest that depth and duration of molecular response are critical factors to enable us to predict the probability of treatment-free remission.
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Affiliation(s)
- David M Ross
- Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,Flinders University and Medical Centre, Adelaide, Australia
| | - Timothy P Hughes
- Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia
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Ning L, Hu C, Lu P, Que Y, Zhu X, Li D. Trends in disease burden of chronic myeloid leukemia at the global, regional, and national levels: a population-based epidemiologic study. Exp Hematol Oncol 2020; 9:29. [PMID: 33292593 PMCID: PMC7607878 DOI: 10.1186/s40164-020-00185-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Outcomes of chronic myeloid leukemia (CML) has been improved dramatically in the past two decades, but survival levels of CML patients varied in regions. Comprehensive epidemiological research is necessary to evaluate the global burden of CML. METHODS All data used in our study came from the Global Burden of Disease (GBD) study 2017. Incidence cases, death cases, disability-adjusted life-years (DALYs), and its corresponding age-standardized rate between 1990 to 2017 were used to describe the distribution of CML burden, according to age, sex, social-demographic index (SDI), and countries. Data about attributable risk factors contributing to CML deaths and DALYs were also extracted and analyzed. RESULTS Globally, the disease burden of CML gradually decreased from 1990 to 2017. Higher SDI countries achieved a remarkable effect on diminishing the CML burden. Conversely, due to population growth, the incidence cases, death cases, and DALYs of CML in lower SDI quintiles showed an upward trend. India had the most incidence cases and death cases of CML in the world. Additionally, smoking was the most significant attributable risk factor contributing to CML deaths and DALYs, followed by high body mass index. CONCLUSION The disease burden of CML decreased globally, especially in higher SDI countries in the past 28 years. The increasing incidence cases and death cases were mainly observed in lower SDI countries. Additionally, strategies to control modifiable risk factors such as smoking and high body mass index might be useful in diminishing mortality and DALYs.
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Affiliation(s)
- Liqing Ning
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chuanyu Hu
- Department of Stomatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Pingfan Lu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yimei Que
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Dengju Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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