1
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Wei W, Li S, Zhang Y, Deng S, He Q, Zhao X, Xu Y, Yu L, Ye J, Zhao W, Jiang Z. Analytical validation of the DropXpert S6 system for diagnosis of chronic myelocytic leukemia. LAB ON A CHIP 2024; 24:3080-3092. [PMID: 38747247 DOI: 10.1039/d4lc00175c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Digital PCR is a powerful method for absolute nucleic acid quantification and is widely used in the absolute quantification of viral copy numbers, tumor marker detection, and prenatal diagnosis. However, for most of the existing droplet-based dPCR systems, the droplet generation, PCR reaction, and droplet detection are performed separately using different instruments. Making digital PCR both easy to use and practical by integrating the qPCR workflow into a superior all-in-one walkaway solution is one of the core ideas. A new innovative and integrated digital droplet PCR platform was developed that utilizes cutting-edge microfluidics to integrate dPCR workflows onto a single consumable chip. This makes previously complex workflows fast and simple; the whole process of droplet generation, PCR amplification, and droplet detection is completed on one chip, which meets the clinical requirement of "sample in, result out". It provides high multiplexing capabilities and strong sensitivity while all measurements were within the 95% confidence interval. This study is the first validation of the DropXpert S6 system and focuses primarily on verifying its reliability, repeatability, and consistency. In addition, the accuracy, detection limit, linearity, and precision of the system were evaluated after sample collection. Among them, the accuracy assessment by calculating the absolute bias of each target gene yielded a range from -0.1 to 0.08, all within ±0.5 logarithmic orders of magnitude; the LOB for the assay was set at 0, and the LoD value calculated using probit curves is MR4.7 (0.002%); the linearity evaluation showed that the R2 value of the BCR-ABL was 0.9996, and the R2 value of the ABL metrics calculated using the ERM standard was 0.9999; and the precision evaluation showed that all samples had a CV of less than 4% for intra-day, inter-day, and inter-instrument variation. The CV of inter-batch variation was less than 7%. The total CV was less than 5%. The results of the study demonstrate that dd-PCR can be applied to molecular detection and the clinical evaluation of CML patients and provide more precise personal treatment guidance, and its reproducibility predicts the future development of a wide range of clinical applications.
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Affiliation(s)
- Wenjia Wei
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Shujun Li
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Ying Zhang
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Simin Deng
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Qun He
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Xielan Zhao
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Yajing Xu
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
| | - Linfen Yu
- Shenzhen Biorain Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Junwei Ye
- Shenzhen Biorain Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Weiwei Zhao
- Rehabilitation Medical Center of Jiangning Hospital, Nanjing, Jiangsu, China
| | - Zhiping Jiang
- Xiangya Hospital Central South University Department of Hematology Changsha, Hunan, China.
- Xiangya Hospital Central South University National Clinical Research Center for Geriatric Disorders Changsha, Hunan, China
- Hunan Hematology Oncology Clinical Medical Research Center Changsha, Hunan, China
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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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Kana S, John S, Basu D, Kar R, Nachiappa Ganesh R, Dubashi B. Flow Cytometric Assessment of CD26-Positive Leukemic Stem Cells: A Rapid and Valuable Tool in the Diagnosis and Follow-Up of Chronic Myeloid Leukemia. Cureus 2024; 16:e56944. [PMID: 38665755 PMCID: PMC11044527 DOI: 10.7759/cureus.56944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Context Chronic myeloid leukemia (CML) is a clonal myeloproliferative neoplasm. Recent studies have suggested that CD26-positive leukemic stem cells (LSCs) circulating in peripheral blood are specific for CML. Objective This study was undertaken to determine the proportion of CD26-positive LSCs at diagnosis and its change during tyrosine kinase inhibitor therapy. Design This prospective study was conducted on 43 cases of CML at diagnosis. For flow cytometry, peripheral blood cells were stained with CD45, CD34, CD38, CD3, and CD26. A sequential gating strategy with CD45/SSC (side scatter), CD34/SSC, and CD34/CD38 was applied to identify CD45+/34+/38- populations, from which CD26-positive stem cells were identified and compared with controls. Data analysis was done with Kaluza software. Results All patients diagnosed with CML were detected with CD26-positive LSCs. The median percentage of CD26-positive CML LSCs was 0.02 with a range of 0.001 to 1.77. None of the control samples showed CD26 positivity. The percentage and absolute count of CD26-positive CML LSCs were reduced after six months of tyrosine kinase therapy in patients with complete hematological remission. Conclusion Flow cytometric analysis of circulating CD26-positive CML LSCs is a non-invasive, rapid, and useful tool in the diagnosis and follow-up of CML.
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Affiliation(s)
- Sreerag Kana
- Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Sarah John
- Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Debdatta Basu
- Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Rakhee Kar
- Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Rajesh Nachiappa Ganesh
- Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Biswajit Dubashi
- Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Hoosen S, Mackraj I, Rapiti N. The Success of Treatment Free Remission in Chronic Myeloid Leukaemia in Clinical Practice: A Single-Centre Retrospective Experience from South Africa. Adv Hematol 2023; 2023:2004135. [PMID: 37547186 PMCID: PMC10403330 DOI: 10.1155/2023/2004135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 07/07/2023] [Accepted: 07/15/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Chronic myeloid leukaemia (CML) management has evolved from a disease once considered to be incurable just over 2 decades ago to that of one of a "functional cure" as defined by the sustained molecular response on stopping tyrosine kinase inhibitor(TKI) therapy. The next goal of CML management has been treatment-free remission (TFR). The past 4 years have seen much international data on TFR attempts in CML in clinical practice. However, Africa as a continent has lagged behind the rest of the world, in keeping up with the latest trends in CML management, and so this study aims to address this gap by assessing the outcome of TFR in CML in a single centre in South Africa (SA). Methods We conducted a retrospective cohort study in 12 CML patients in the chronic phase to assess the success of TKI discontinuation. The patients were treated in King Edward VIII Hospital (KEH), a tertiary, academic hospital in KwaZulu-Natal, South Africa, and the study period was from June 2020 to May 2022. Patients included had to have been on TKI therapy for a minimum of 5 years and achieved a deep molecular response (DMR) for a minimum period of 3 years. Results The overall TFR cohort showed a success rate of 75% at a median follow-up of 12 months. All patients who failed TFR, defined as a loss of major molecular remission (MMR), failed within 6 months of stopping TKI therapy. All patients who failed TFR regained DMR after retreatment with TKI, with no disease progression reported. The only factor influencing the success of TFR was the total period of TKI therapy. Conclusion Despite our study having a small cohort of patients, this study demonstrated that TFR in CML is an attainable goal, even in a resource-limited setting.
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Affiliation(s)
- Siddeeq Hoosen
- University of KwaZulu-Natal, School of Laboratory Medicine and Health Sciences, Durban, South Africa
- National Health Laboratory Service, IALCH, Department of Haematology, Durban, South Africa
- King Edward VIII Hospital, Department of Clinical Haematology, Durban, South Africa
| | - Irene Mackraj
- University of KwaZulu-Natal, School of Laboratory Medicine and Health Sciences, Durban, South Africa
| | - Nadine Rapiti
- University of KwaZulu-Natal, School of Laboratory Medicine and Health Sciences, Durban, South Africa
- National Health Laboratory Service, IALCH, Department of Haematology, Durban, South Africa
- King Edward VIII Hospital, Department of Clinical Haematology, Durban, South Africa
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5
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Marin AM, Wosniaki DK, Sanchuki HBS, Munhoz EC, Nardin JM, Soares GS, Espinace DC, de Holanda Farias JS, Veroneze B, Becker LF, Costa GL, Beltrame OC, de Oliveira JC, Cambri G, Zanette DL, Aoki MN. Molecular BCR::ABL1 Quantification and ABL1 Mutation Detection as Essential Tools for the Clinical Management of Chronic Myeloid Leukemia Patients: Results from a Brazilian Single-Center Study. Int J Mol Sci 2023; 24:10118. [PMID: 37373266 DOI: 10.3390/ijms241210118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic myeloid leukemia (CML) is a well-characterized oncological disease in which virtually all patients possess a translocation (9;22) that generates the tyrosine kinase BCR::ABL1 protein. This translocation represents one of the milestones in molecular oncology in terms of both diagnostic and prognostic evaluations. The molecular detection of the BCR::ABL1 transcription is a required factor for CML diagnosis, and its molecular quantification is essential for assessing treatment options and clinical approaches. In the CML molecular context, point mutations on the ABL1 gene are also a challenge for clinical guidelines because several mutations are responsible for tyrosine kinase inhibitor resistance, indicating that a change may be necessary in the treatment protocol. So far, the European LeukemiaNet and the National Comprehensive Cancer Network (NCCN) have presented international guidelines on CML molecular approaches, especially those related to BCR::ABL1 expression. In this study, we show almost three years' worth of data regarding the clinical treatment of CML patients at the Erasto Gaertner Hospital, Curitiba, Brazil. These data primarily comprise 155 patients and 532 clinical samples. BCR::ABL1 quantification by a duplex-one-step RT-qPCR and ABL1 mutations detection were conducted. Furthermore, digital PCR for both BCR::ABL1 expression and ABL1 mutations were conducted in a sub-cohort. This manuscript describes and discusses the clinical importance and relevance of molecular biology testing in Brazilian CML patients, demonstrating its cost-effectiveness.
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Affiliation(s)
- Anelis Maria Marin
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | - Denise Kusma Wosniaki
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | - Heloisa Bruna Soligo Sanchuki
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | | | | | - Gabriela Silva Soares
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | - Dhienifer Caroline Espinace
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | | | | | | | | | | | | | - Geison Cambri
- Instituto de Biologia Molecular do Paraná (IBMP), Curitiba 81350-010, Brazil
| | - Dalila Luciola Zanette
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
| | - Mateus Nóbrega Aoki
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba 81350-010, Brazil
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6
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Nishiyama-Fujita Y, Nakazato T, Iriyama N, Tokuhira M, Ishikawa M, Sato E, Takaku T, Sugimoto K, Fujita H, Fujioka I, Tsuchiya S, Kimura Y, Iwanaga E, Komatsu N, Asou N, Kizaki M, Hatta Y, Kawaguchi T. Outcomes of adolescents and young adults with chronic-phase chronic myeloid leukaemia treated with tyrosine kinase inhibitors. Ann Med 2022; 54:1244-1254. [PMID: 35486442 PMCID: PMC9126594 DOI: 10.1080/07853890.2022.2069280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Few studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs). MATERIALS AND METHODS We retrospectively analysed the clinical features, treatment response, and long-term outcomes of 42 AYA patients, in comparison to older patients. The initial therapies of AYA patients between 2001 and 2016 included imatinib (n = 24), dasatinib (n = 13) and nilotinib (n = 5). RESULTS In AYA patients, the peripheral blood (PB) white blood cell count and percentage of blasts at the diagnosis were significantly higher, haemoglobin levels were lower and the spleen size was larger. The major molecular response (MMR), event-free survival (EFS) and overall survival (OS) rates were comparable. A sub-analysis comparing imatinib to second-generation TKIs as the initial therapy also showed that their prognosis was comparable. DISCUSSION In conclusion, the tumour burden at the diagnosis of CML-CP is higher in AYA patients; however, their prognosis was not worse in comparison to older patients treated with TKIs. KEY MESSAGESFew studies have reported the outcomes of adolescents and young adults (AYAs) with chronic-phase chronic myeloid leukaemia (CML-CP) on tyrosine kinase inhibitors (TKIs). This study showed the tumour burden at the diagnosis of CML-CP is higher in AYA pa tients; however, their prognosis was not worse in comparison to older patients treated with TKIs. Understanding the biological and non-biological features of AYA patients with CML-CP on TKI therapy is essential for better management and to improve the outcomes.
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Affiliation(s)
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Noriyoshi Iriyama
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Maho Ishikawa
- Department of Hemato-Oncology, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Eriko Sato
- Department of Hematology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomoiku Takaku
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keiji Sugimoto
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Isao Fujioka
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shun Tsuchiya
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuta Kimura
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Eisaku Iwanaga
- Department of Hematology, Kumamoto University Hospital, Kumamoto, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Asou
- Department of Hemato-Oncology, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshihiro Hatta
- Department of Medicine, Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Tatsuya Kawaguchi
- Medical Technology, Kumamoto Health Science University, Kumamoto, Japan
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7
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Cantoni N, Sommavilla R, Seitz P, Kulenkampff E, Kahn S, Lambert JF, Schmidt A, Zenhaeusern R, Balabanov S. A multicenter real-world evidence study in the Swiss treatment landscape of chronic myeloid leukemia. BMC Cancer 2022; 22:1192. [PMCID: PMC9675134 DOI: 10.1186/s12885-022-10241-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background The real-world experience of Swiss chronic myeloid leukemia (CML) patients treated with tyrosine kinase inhibitors (TKIs) is largely unknown, in particular with regard to achievement of response per European Leukemia Net (ELN) criteria and adherence to ELN recommendations. Methods This was a retrospective, non-interventional, multicenter chart review of patients with newly diagnosed CML who had received first-line TKI and were solely treated with TKIs between 2010 and 2015, with a minimum follow-up of 18 months, at six Swiss hospitals. Effectiveness was evaluated according to ELN 2013 milestone achievements at 3, 6, 12 and 18 months, and at last follow-up. Results Data from 63 patients (56% men; median age at diagnosis 55 years) were collected (first-line imatinib [n = 27], nilotinib [n = 27], dasatinib [n = 8], or ponatinib [n = 1]). TKI switches (49 times) and dosing changes (165 times) due to intolerance or insufficient response were frequent. Compared with patients receiving first-line imatinib, a higher proportion of patients receiving first-line nilotinib or dasatinib achieved optimal response at all timepoints, irrespective of subsequent TKI therapy, and a higher proportion of patients treated with first-line nilotinib and dasatinib reached deep molecular response (BCR-ABL1IS ≤ 0.01%) at 18 months (42 and 38%, respectively, versus 27%). Patients who received nilotinib or dasatinib switched therapies less frequently than patients treated with imatinib, irrespective of subsequent TKI therapy. Conclusions Although patient numbers were small, this real-world evidence study with patients with CML confirms that ELN guidelines are generally implemented in Swiss clinical practice, with a large proportion of patients achieving ELN 2013 milestones. While TKI use involved all inhibitors approved at the time of the study, an unexpectedly high number of TKI therapy switches suggests a clear difference in TKI use between registration trials and clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10241-y.
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Affiliation(s)
- Nathan Cantoni
- grid.413357.70000 0000 8704 3732Kantonsspital Aarau, Aarau, Switzerland
| | | | | | | | - Stefan Kahn
- Novartis Pharma Schweiz, Rotkreuz, Switzerland
| | | | | | | | - Stefan Balabanov
- grid.412004.30000 0004 0478 9977Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zürich, Switzerland
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8
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Okamoto Y, Hirano M, Morino K, Kajita MK, Nakaoka S, Tsuda M, Sugimoto KJ, Tamaki S, Hisatake J, Yokoyama H, Igarashi T, Shinagawa A, Sugawara T, Hara S, Fujikawa K, Shimizu S, Yujiri T, Wakita H, Nishiwaki K, Tojo A, Aihara K. Early dynamics of chronic myeloid leukemia on nilotinib predicts deep molecular response. NPJ Syst Biol Appl 2022; 8:39. [PMID: 36229495 PMCID: PMC9561725 DOI: 10.1038/s41540-022-00248-3] [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: 02/22/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disorder caused by the BCR-ABL1 tyrosine kinase. Although ABL1-specific tyrosine kinase inhibitors (TKIs) including nilotinib have dramatically improved the prognosis of patients with CML, the TKI efficacy depends on the individual patient. In this work, we found that the patients with different nilotinib responses can be classified by using the estimated parameters of our simple dynamical model with two common laboratory findings. Furthermore, our proposed method identified patients who failed to achieve a treatment goal with high fidelity according to the data collected only at three initial time points during nilotinib therapy. Since our model relies on the general properties of TKI response, our framework would be applicable to CML patients who receive frontline nilotinib or other TKIs.
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Affiliation(s)
- Yuji Okamoto
- Institute of Industrial Science, The University of Tokyo, Tokyo, 153-8505, Japan.,Division of Molecular Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan.,Department of Biomedical Data Intelligence, Graduate School of Medicine, Kyoto University, Kyoto, 606-8507, Japan
| | - Mitsuhito Hirano
- Division of Molecular Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan
| | - Kai Morino
- Institute of Industrial Science, The University of Tokyo, Tokyo, 153-8505, Japan.,Interdisciplinary Graduate School of Engineering Sciences, Kyushu University, Fukuoka, 816-8580, Japan
| | - Masashi K Kajita
- Institute of Industrial Science, The University of Tokyo, Tokyo, 153-8505, Japan. .,Department of Applied Chemistry and Biotechnology, Faculty of Engineering, University of Fukui, Fukui, 910-8507, Japan. .,Life Science Innovation Center, University of Fukui, Fukui, 910-8507, Japan.
| | - Shinji Nakaoka
- Institute of Industrial Science, The University of Tokyo, Tokyo, 153-8505, Japan.,Faculty of Advanced Life Science, Hokkaido University, Hokkaido, 060-0810, Japan.,PRESTO, Japan Science and Technology Agency, Tokyo, 102-0076, Japan
| | - Mayuko Tsuda
- Division of Molecular Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan
| | - Kei-Ji Sugimoto
- Division of Hematology, Juntendo University Urayasu Hospital, Chiba, 279-0021, Japan
| | - Shigehisa Tamaki
- Department of Hematology, Japanese Red Cross Ise Hospital, Mie, 516-8512, Japan
| | - Junichi Hisatake
- Department of Hematology, Japanese Red Cross Omori Hospital, Tokyo, 143-8527, Japan
| | - Hisayuki Yokoyama
- Department of Hematology, National Hospital Organization, Sendai Medical Center, Miyagi, 983-8520, Japan
| | - Tadahiko Igarashi
- Divison of Hematology and Oncology, Gunma Cancer Center, Gunma, 373-8550, Japan
| | - Atsushi Shinagawa
- Department of Internal Medicine, Hitachi General Hospital, Ibaraki, 317-0077, Japan
| | - Takeaki Sugawara
- Division of Hematology-Oncology, Chiba Cancer Center, Chiba, 260-8717, Japan
| | - Satoru Hara
- Department of Hematology, Chiba Rosai Hospital, Chiba, 290-0003, Japan
| | - Kazuhisa Fujikawa
- Department of Hematology, Chibaken Saiseikai Narashino Hospital, Chiba, 275-8580, Japan
| | - Seiichi Shimizu
- Department of Hematology, Tsuchiura Kyodo General Hospital, Ibaraki, 300-0028, Japan
| | - Toshiaki Yujiri
- Third Department of Internal Medicine, Yamaguchi University, Yamaguchi, 755-0046, Japan
| | - Hisashi Wakita
- Division of Hematology and Oncology, Japanese Red Cross Narita Hospital, Chiba, 286-8523, Japan
| | - Kaichi Nishiwaki
- Division of Oncology and Hematology, Jikei University Kashiwa Hospital, Chiba, 277-8567, Japan
| | - Arinobu Tojo
- Division of Molecular Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan.,Institute of Innovation Advancement, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Kazuyuki Aihara
- Institute of Industrial Science, The University of Tokyo, Tokyo, 153-8505, Japan. .,International Research Center for Neurointelligence (WPI-IRCN), The University of Tokyo, Tokyo, 113-0033, Japan.
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9
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Mehra N, Varmeziar A, Chen X, Kronick O, Fisher R, Kota V, Mitchell CS. Cross-Domain Text Mining to Predict Adverse Events from Tyrosine Kinase Inhibitors for Chronic Myeloid Leukemia. Cancers (Basel) 2022; 14:4686. [PMID: 36230609 PMCID: PMC9563938 DOI: 10.3390/cancers14194686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/04/2022] [Accepted: 09/23/2022] [Indexed: 12/02/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are prescribed for chronic myeloid leukemia (CML) and some other cancers. The objective was to predict and rank TKI-related adverse events (AEs), including under-reported or preclinical AEs, using novel text mining. First, k-means clustering of 2575 clinical CML TKI abstracts separated TKIs by significant (p < 0.05) AE type: gastrointestinal (bosutinib); edema (imatinib); pulmonary (dasatinib); diabetes (nilotinib); cardiovascular (ponatinib). Next, we propose a novel cross-domain text mining method utilizing a knowledge graph, link prediction, and hub node network analysis to predict new relationships. Cross-domain text mining of 30+ million articles via SemNet predicted and ranked known and novel TKI AEs. Three physiology-based tiers were formed using unsupervised rank aggregation feature importance. Tier 1 ranked in the top 1%: hematology (anemia, neutropenia, thrombocytopenia, hypocellular marrow); glucose (diabetes, insulin resistance, metabolic syndrome); iron (deficiency, overload, metabolism), cardiovascular (hypertension, heart failure, vascular dilation); thyroid (hypothyroidism, hyperthyroidism, parathyroid). Tier 2 ranked in the top 5%: inflammation (chronic inflammatory disorder, autoimmune, periodontitis); kidney (glomerulonephritis, glomerulopathy, toxic nephropathy). Tier 3 ranked in the top 10%: gastrointestinal (bowel regulation, hepatitis, pancreatitis); neuromuscular (autonomia, neuropathy, muscle pain); others (secondary cancers, vitamin deficiency, edema). Results suggest proactive TKI patient AE surveillance levels: regular surveillance for tier 1, infrequent surveillance for tier 2, and symptom-based surveillance for tier 3.
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Affiliation(s)
- Nidhi Mehra
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
| | - Armon Varmeziar
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
| | - Xinyu Chen
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
| | - Olivia Kronick
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
| | - Rachel Fisher
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
| | - Vamsi Kota
- Division of Hematology and Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA
| | - Cassie S. Mitchell
- Laboratory for Pathology Dynamics, Department of Biomedical Engineering, Georgia Institute of Technology, Emory University School of Medicine, Atlanta, GA 30332, USA
- Center for Machine Learning, Georgia Institute of Technology, Atlanta, GA 30332, USA
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10
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Pemmaraju N, Verstovsek S, Mesa R, Gupta V, Garcia JS, Scandura JM, Oh ST, Passamonti F, Döhner K, Mead AJ. Defining disease modification in myelofibrosis in the era of targeted therapy. Cancer 2022; 128:2420-2432. [PMID: 35499819 PMCID: PMC9322520 DOI: 10.1002/cncr.34205] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
The development of targeted therapies for the treatment of myelofibrosis highlights a unique issue in a field that has historically relied on symptom relief, rather than survival benefit or modification of disease course, as key response criteria. There is, therefore, a need to understand what constitutes disease modification of myelofibrosis to advance appropriate drug development and therapeutic pathways. Here, the authors discuss recent clinical trial data of agents in development and dissect the potential for novel end points to act as disease modifying parameters. Using the rationale garnered from latest clinical and scientific evidence, the authors propose a definition of disease modification in myelofibrosis. With improved overall survival a critical outcome, alongside the normalization of hematopoiesis and improvement in bone marrow fibrosis, there will be an increasing need for surrogate measures of survival for use in the early stages of trials. As such, the design of future clinical trials will require re-evaluation and updating to incorporate informative parameters and end points with standardized definitions and methodologies.
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Affiliation(s)
- Naveen Pemmaraju
- Department of LeukemiaUniversity of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Srdan Verstovsek
- Department of LeukemiaUniversity of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ruben Mesa
- UT Health San Antonio Cancer CenterSan AntonioTexasUSA
| | - Vikas Gupta
- Princess Margaret Cancer CentreUniversity of TorontoTorontoOntarioCanada
| | | | - Joseph M. Scandura
- Department of MedicineHematology‐OncologyWeill Cornell Medicine and the New York Presbyterian HospitalNew YorkNew YorkUSA
| | - Stephen T. Oh
- Department of MedicineWashington University School of MedicineSt. LouisMissouriUSA
| | | | - Konstanze Döhner
- Department of Internal Medicine IIIUniversity HospitalUlmGermany
| | - Adam J. Mead
- MRC Molecular Haematology UnitMRC Weatherall Institute of Molecular Medicine, National Institute for Health Research Oxford Biomedical Research Centre, University of OxfordOxfordUnited Kingdom
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11
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Robin JB, Theron A, Quittet P, Exbrayat C, Gaillard JB, Lavabre-Bertrand T, David S, Saad A, Jourdan E, Cartron G. Discontinuation of tyrosine kinase inhibitor in chronic myeloid leukemia: a retrospective cohort in east occitania. Ann Hematol 2022; 101:1015-1022. [DOI: 10.1007/s00277-022-04779-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 01/30/2022] [Indexed: 11/28/2022]
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12
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Integrated Genomic Analysis Identifies ANKRD36 Gene as a Novel and Common Biomarker of Disease Progression in Chronic Myeloid Leukemia. BIOLOGY 2021; 10:biology10111182. [PMID: 34827175 PMCID: PMC8615070 DOI: 10.3390/biology10111182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 02/05/2023]
Abstract
Simple Summary Chronic myeloid leukemia is a type of blood cancer that is regarded as a success story in determining the exact biological origin, pathogenesis and development of a molecularly targeted (mutation-specific) therapy that has led to successful treatment of this fatal cancer. It is caused by the BCR-ABL fusion gene, which is formed from the translocation between chromosomes 9 and 22. Anti-BCR-ABL drugs, known as tyrosine kinase inhibitors (TKIs), have led to long-term remissions in more than 80% of CML patients and even cure in about one-third of patients. Nevertheless, many patients face drug resistance, and disease progression occurs in about 30% of CML patients, leading to morbidities and mortality. Unfortunately, no biomarkers of CML progression are available due to a poor understanding of the mechanism of progression. Therefore, finding reliable molecular biomarkers of CML progression is one of the most attractive research areas in 21st-century cancer research. In this study, we report novel genomic variants exclusively found in all our advanced-phase CML patients. This study will help in identifying CML patients at risk of disease progression and timely therapeutic interventions to avoid or at least delay fatal disease progression in this cancer. Abstract Background: Chronic myeloid leukemia (CML) is initiated in bone marrow due to chromosomal translocation t(9;22) leading to fusion oncogene BCR-ABL. Targeting BCR-ABL by tyrosine kinase inhibitors (TKIs) has changed fatal CML into an almost curable disease. Despite that, TKIs lose their effectiveness due to disease progression. Unfortunately, the mechanism of CML progression is poorly understood and common biomarkers for CML progression are unavailable. This study was conducted to find novel biomarkers of CML progression by employing whole-exome sequencing (WES). Materials and Methods: WES of accelerated phase (AP) and blast crisis (BC) CML patients was carried out, with chronic-phase CML (CP-CML) patients as control. After DNA library preparation and exome enrichment, clustering and sequencing were carried out using Illumina platforms. Statistical analysis was carried out using SAS/STAT software version 9.4, and R package was employed to find mutations shared exclusively by all AP-/BC-CML patients. Confirmation of mutations was carried out using Sanger sequencing and protein structure modeling using I-TASSER followed by mutant generation and visualization using PyMOL. Results: Three novel genes (ANKRD36, ANKRD36B and PRSS3) were mutated exclusively in all AP-/BC-CML patients. Only ANKRD36 gene mutations (c.1183_1184 delGC and c.1187_1185 dupTT) were confirmed by Sanger sequencing. Protein modeling studies showed that mutations induce structural changes in ANKRD36 protein. Conclusions: Our studies show that ANKRD36 is a potential common biomarker and drug target of early CML progression. ANKRD36 is yet uncharacterized in humans. It has the highest expression in bone marrow, specifically myeloid cells. We recommend carrying out further studies to explore the role of ANKRD36 in the biology and progression of CML.
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Park H, Kim I, Kim HJ, Shin DY, Lee SY, Kwon OH, Kim DY, Lee KH, Ahn JS, Park J, Sohn SK, Lee JO, Cheong JW, Kim KH, Kim HG, Kim H, Lee YJ, Nam SH, Do YR, Park SG, Park SK, Bae SH, Song HH, Oh D, Jung CW, Park S. Ultra-deep sequencing mutation analysis of the BCR/ABL1 kinase domain in newly diagnosed chronic myeloid leukemia patients. Leuk Res 2021; 111:106728. [PMID: 34673444 DOI: 10.1016/j.leukres.2021.106728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022]
Abstract
Ultra-deep sequencing detects low-frequency genetic mutations with high sensitivity. We used this approach to prospectively examine mutations in the BCR/ABL1 tyrosine kinase from patients with newly diagnosed, chronic-phase chronic myeloid leukemia (CML) treated with the tyrosine kinase inhibitor nilotinib. Between May 2013 and November 2014, 50 patients from 18 institutions were enrolled in the study. We screened 103 somatic mutations and found that mutations in the P-loop domain were the most frequent (173/454 mutations in the P-loop) and noted the presence of the V299 L mutation (dasatinib-resistant/nilotinib-sensitive) in 98 % of patients (49/50). No patients had Y253H, E255 V, or F359 V/C/I mutations, which would recommend dasatinib rather than nilotinib treatment. The S417Y mutation was associated with lower achievement of a major molecular response (MMR) at 6 months, and the V371A mutation was associated with reduced MMR and MR4.5 durations (MMR for 2 years: 100 % for no mutation vs. 75 % for mutation, P=0.039; MR4.5 for 15 months: 94.1 % vs. 25 %, P=0.002). Patients with known nilotinib-resistant mutations had lower rates of MR4.5 achievement. In conclusion, ultra-deep sequencing is a sensitive method for genetic-based treatment decisions. Based on the results of these mutational analyses, nilotinib treatment is a promising option for Korean patients with CML.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, Seoul National University Hospital, Biomedical Research Institute, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea; Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Biomedical Research Institute, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
| | - Hyeong-Joon Kim
- Department of Internal Medicine, Chonnam National University, Hwasun Hospital, Hwasun, South Korea.
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Biomedical Research Institute, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | | | - Dae-Young Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyoo-Hyung Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae-Sook Ahn
- Department of Internal Medicine, Chonnam National University, Hwasun Hospital, Hwasun, South Korea
| | - Jinny Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, South Korea
| | - Sang-Kyun Sohn
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, South Korea
| | - June-Won Cheong
- Department of Internal Medicine, Yonsei University, Severance Hospital, Seoul, South Korea
| | - Kyoung Ha Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Hoon-Gu Kim
- Department of Internal Medicine, Gyeongsang Institute of Health Sciences, Gyeongsang National University College of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Hawk Kim
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Seung-Hyun Nam
- Department of Internal Medicine, VHS Medical Center, Seoul, South Korea
| | - Young Rok Do
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Sang-Gon Park
- Department of Internal Medicine, Chosun University Hospital, Gwangju, South Korea
| | - Seong Kyu Park
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, South Korea
| | - Hun Ho Song
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Doyeun Oh
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, South Korea
| | - Chul Won Jung
- Department of Internal Medicine, Samsung Medical Center, Seoul, South Korea
| | - Seonyang Park
- Department of Internal Medicine, Inje University, Haeundae Paik Hospital, Busan, South Korea
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Aznab M, Shahriari-Ahmadi A, Heydarpour F. Evaluation of the outcomes in patients with chronic myeloid leukemia treated with imatinib in 18-year follow-up. Leuk Res Rep 2021; 16:100271. [PMID: 34631408 PMCID: PMC8487986 DOI: 10.1016/j.lrr.2021.100271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 08/11/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022] Open
Abstract
The objective of this paper is to examine the effects of Imatinib on patients who are at the chronic phase of chronic myeloid leukemia (CML). Method: Totally, 79 patients with CML who received the treatment between 2003 and 2020 entered the study. The patients were evaluated in terms of molecular response rate and overall survival (OS). Results: About 75.9% of patients achieved deep molecular response in mean follow-up of 89.92 months. The OS rate was about 91.2%. Conclusion: There was no considerable cumulative toxicity with Imatinib long-term use. A high percent of patients had a deep molecular response.
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Affiliation(s)
- Mozafar Aznab
- Internal Medicine Department,Medical Oncologist Hematologist, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Shahriari-Ahmadi
- Medical Oncologist-Hematologist, Iran University for Medical sciences, Tehran, Iran
| | - Fatemeh Heydarpour
- Internal Medicine Department,Medical Oncologist Hematologist, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Corresponding author at: PHD in Epidemiology, Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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15
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Karasu N, Akalin H, Gokce N, Yildirim A, Demir M, Kulak H, Celik S, Keklik M, Dundar M. Detection of mutations in CML patients resistant to tyrosine kinase inhibitor: imatinib mesylate therapy. Med Oncol 2021; 38:120. [PMID: 34453624 DOI: 10.1007/s12032-021-01571-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
Imatinib mesylate, a tyrosine kinase inhibitor, is the first choice in chronic myeloid leukemia treatment. However, resistance to imatinib may develop with time and in some cases, patients may not respond at all to imatinib. Progressive resistance to imatinib therapy is often due to mutations in the BCR/ABL region. Within the scope of our study 124 patients were evaluated via pyrosequencing between 2015 and 2020. In this regard, 32 patients who have a partial response and have no response to imatinib therapy were included in the study. In addition, next-generation sequencing (NGS) analysis was performed on 15 patients who were resistant to imatinib treatment according to the molecular follow-up reports. With pyrosequencing, 5 cases out of a total of 124 were found to be positive. This means that approximately 4.03% of the proportion is positive. But when we examined only 32 patients who have a partial response and have no response to imatinib therapy this rate is rising 15.6%. NGS analysis was performed with 15 patients who have no mutation with pyrosequencing of 32 patients and VUS (Variant of Uncertain Significance) mutation was detected in one. In this study, our aim was to determine the mutations of the BCR/ABL and to evaluate the mutations by NGS and pyrosequencing. Our study is important in terms of comparing the pyrosequencing with NGS mutation rates, drawing attention to the clinical importance of log reduction.
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Affiliation(s)
- Nilgun Karasu
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Hilal Akalin
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Nuriye Gokce
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Abdulbaki Yildirim
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mikail Demir
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Hande Kulak
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Serhat Celik
- Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Muzaffer Keklik
- Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Munis Dundar
- Department of Medical Genetics, Faculty of Medicine, Erciyes University, Kayseri, Turkey.
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16
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Ilhan O, Narli Ozdemir Z, Dalva K, Arslan A, Okay Ozgeyik M, Ipek S, Saydam G, Haznedaroglu IC. Leukemic stem cells shall be searched in the bone marrow before "tyrosine kinase inhibitor-discontinuation" in chronic myeloid leukemia. Int J Lab Hematol 2021; 43:1110-1116. [PMID: 33834631 DOI: 10.1111/ijlh.13528] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Leukemic stem cells (LSCs) of chronic myeloid leukemia (CML), persisting in the bone marrow (BM) niche, could be responsible for the relapses within the patients of whom the treatment-free remission (TFR) had been attempted. We assessed the presence of the CML LSCs in the peripheral blood (PB) and concurrently in the BM in the patients with chronic-phase CML (CP CML). PATIENTS AND METHODS Thirty-eight patients with CP CML were included into the study. CD45+ /CD34+ /CD38- cells with positive CD26 expression were considered as CML LSCs (CD26+ LSC) by using multiparameter flow cytometry (FCM). RESULTS Mean BCR-ABL, PB LSC, and BM LSC were 58.528 IS (37.405-83.414 IS), 237.5 LSC/μL (16-737.5 LSC/μL), and 805 LSC/106 WBCs (134.6-2470 LSC/106 WBCs), respectively, in newly diagnosed CML patients. In the patients with BCR-ABL positive hematopoiesis, mean BCR-ABL, PB LSCs, and BM LSCs were 30.09 IS (0.024-147.690 IS), 13.5 LSC/μL (0-248.7 LSC/μL) and 143.5 LSC/106 WBCs (9-455.2 LSC/106 WBCs), respectively. No CML LSCs were detected in PB of patients who achieved deep molecular response (DMR). BM LSCs of the patients who were in DMR were 281.1 LSC/106 WBCs (3.1-613.7 LSC/106 WBCs). The amount of PB LSCs was highest in patients with newly diagnosed CML (P < .001). CONCLUSION LSCs persisted in the BM of the patients with DMR, whereas there was no LSCs in the peripheral blood. The investigation of the CML LSCs in bone marrow before deciding TKI discontinuation could be justified to achieve and maintain stable TFR.
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Affiliation(s)
- Osman Ilhan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Zehra Narli Ozdemir
- Department of Hematology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Klara Dalva
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Aysenur Arslan
- Department of Hematology, Ege University School of Medicine, İzmir, Turkey
| | - Mufide Okay Ozgeyik
- Department of Hematology, Ministry of Health Eskisehir City Hospital, Eskisehir, Turkey
| | - Senay Ipek
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Guray Saydam
- Department of Hematology, Ege University School of Medicine, İzmir, Turkey
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Increased tumor burden in patients with chronic myeloid leukemia after 36 months of imatinib discontinuation. Blood 2021; 136:2237-2240. [PMID: 32518953 DOI: 10.1182/blood.2019004371] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/14/2020] [Indexed: 01/12/2023] Open
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Increased Expression of TIGIT/CD57 in Peripheral Blood/Bone Marrow NK Cells in Patients with Chronic Myeloid Leukemia. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9531549. [PMID: 33102599 PMCID: PMC7578715 DOI: 10.1155/2020/9531549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
The antitumor activity of NK cells in patients with chronic myeloid leukemia (CML) is inhibited by the leukemia microenvironment. Recent studies have identified that the expression of TIGIT, CD57, and KLRG1 is related to the function, maturation, and antitumor capabilities of NK cells. However, the characteristics of the expression of these genes in the peripheral blood (PB) and bone marrow (BM) from patients with CML remain unknown. In this study, we used multicolor flow cytometry to assay the quantity and phenotypic changes of NK cells in PB and BM from de novo CML (DN-CML) and CML patients acquiring molecular response (MR-CML). We found that the expression of TIGIT, which inhibits NK cell function, is increased on CD56+ and CD56dim NK cells in DN-CML PB compared with those in healthy individuals (HIs), and it is restored to normal in patients who achieve MR. We also found that the expression of CD57 on NK cells was approximately the same level in PB and BM from DN-CML patients, while decreased CD57 expression was found on CD56+ and CD56dim NK cells in HI BM compared with PB. Additionally, those two subsets were significantly increased in DN-CML BM compared to HI BM. The expression of CD57 correlates with replicative senescence and maturity for human NK cells; therefore, the increase in TIGIT on PB NK cells together with an increase in CD57 on BM NK cells may explain the subdued NK cell antileukemia capacity and proliferative ability in DN-CML patients. These results indicate that reversing the immune suppression of PB NK cells by blocking TIGIT while improving the proliferation of BM NK cells via targeting CD57 may be more effective in removing tumor cells.
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Abstract
Purpose of Review For patients with chronic phase chronic myeloid leukemia (CP-CML), there is an increasing focus on personalization of therapy with dose modifications of tyrosine kinase inhibitors (TKIs) to reduce side effects and maintain efficacy. Dose reductions are also being considered in clinical trials prior to treatment-free remission (TFR) attempts. Recent Findings Recent retrospective analyses of large clinical trials show that dose modification/reduction is safe. Efficacy is generally maintained and side effects are improved. Clinical trials such as DESTINY have demonstrated that dose reduction is safe for patients in deep molecular remission and may be considered prior to a TFR attempt. Summary Dose modifications are widely used to prevent and manage the toxicities of TKIs. With adequate monitoring, dose optimization is safe, reduces side effects, and improves quality-of-life for patients. Clinical trials of dose optimization are currently recruiting across all approved TKIs and will lead to further personalization of therapy for CP-CML patients in the future.
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Brümmendorf TH, Gambacorti-Passerini C, Bushmakin AG, Cappelleri JC, Viqueira A, Reisman A, Isfort S, Mamolo C. Relationship between molecular response and quality of life with bosutinib or imatinib for chronic myeloid leukemia. Ann Hematol 2020; 99:1241-1249. [PMID: 32307568 PMCID: PMC7237399 DOI: 10.1007/s00277-020-04018-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/30/2020] [Indexed: 12/01/2022]
Abstract
Patients with newly diagnosed chronic phase chronic myeloid leukemia (CP CML) can be effectively treated with tyrosine kinase inhibitors (TKIs) and achieve a lifespan similar to the general population. The success of TKIs, however, requires long-term and sometimes lifelong treatment; thus, patient-assessed health-related quality of life (HRQoL) has become an increasingly important parameter for treatment selection. Bosutinib is a TKI approved for CP CML in newly diagnosed adults and in those resistant or intolerant to prior therapy. In the Bosutinib Trial in First-Line Chronic Myelogenous Leukemia Treatment (BFORE), bosutinib demonstrated a significantly higher major molecular response rate compared with imatinib, with maintenance of HRQoL (measured by the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) questionnaire), after 12 months of first-line treatment. We examined relationships between molecular response (MR) and HRQoL. MR values were represented by a log-reduction scale (MRLR; a continuous variable). A repeated-measures longitudinal model was used to estimate the relationships between MRLR as a predictor and each FACT-Leu domain as an outcome. Effect sizes were calculated to determine strength of effects and allow comparisons across domains. The majority of FACT-Leu domains (with the exception of social well-being and physical well-being) demonstrated a significant relationship with MRLR (p < 0.05). Our results showed variable impact of clinical improvement on different dimensions of HRQoL. For patients who achieved MR5, emotional well-being and leukemia-specific domains showed the greatest improvement, with medium differences in effect sizes, whereas social well-being and physical well-being had the weakest relationship with MR.
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Affiliation(s)
- Tim H Brümmendorf
- Universitätsklinikum RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | | | | | | | | | | | - Susanne Isfort
- Universitätsklinikum RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
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Park H, Shin DY, Kim I, Sohn SK, Koh Y, Lee JH, Lee KH, Kim DY, Kim HJ, Ahn JS, Lee JO, Bang SM, Cheong JW, Park SG, Park S, Lee YJ, Ahn SY. Use of Droplet Digital Polymerase Chain Reaction for Detecting Minimal Residual Disease: A Prospective Multi-Institutional Study. In Vivo 2020; 33:2273-2280. [PMID: 31662567 DOI: 10.21873/invivo.11733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND/AIM Droplet digital polymerase chain reaction (ddPCR) is an exact method of measuring nucleic acids. The aim of this prospective study was to evaluate minimal residual disease (MRD) using ddPCR in chronic myeloid leukemia (CML) patients. PATIENTS AND METHODS Between May 2013 and November 2014, CML patients treated with nilotinib were enrolled in our study. BCR/ABL1 transcripts levels were evaluated using ddPCR at the first time of complete molecular response (CMR). We enrolled 15 patients from 7 Institutions. The treatment period and median follow-up period were 45 months and 47 months, respectively. RESULTS Patients with a high level of BCR/ABL1 transcript had a greater tendency to lose the CMR during the follow-up period (p=0.095). In addition, patients with a low level of BCR/ABL1 transcript showed a longer duration of CMR compared to those with a high level (p=0.032). CONCLUSION We found that ddPCR is a sensitive method for detecting MRD and that MRD could affect the duration of the treatment response.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, Biomedical Research Institute, Cancer Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Biomedical Research Institute, Cancer Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Biomedical Research Institute, Cancer Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Kyun Sohn
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Biomedical Research Institute, Cancer Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Je-Hwan Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoo-Hyung Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeong-Joon Kim
- Department of Internal Medicine, Chonnam National University, Hwasun Hospital, Hwasun, Republic of Korea
| | - Jae-Sook Ahn
- Department of Internal Medicine, Chonnam National University, Hwasun Hospital, Hwasun, Republic of Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Republic of Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University, Bundang Hospital, Seongnam, Republic of Korea
| | - June-Won Cheong
- Department of Internal Medicine, Yonsei University, Severance Hospital, Seoul, Republic of Korea
| | - Sang-Gon Park
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Republic of Korea
| | - Seonyang Park
- Department of Internal Medicine, Biomedical Research Institute, Cancer Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Inje University, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seo-Yeon Ahn
- Department of Internal Medicine, Chonnam National University, Hwasun Hospital, Hwasun, Republic of Korea
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22
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Moisoiu V, Teodorescu P, Parajdi L, Pasca S, Zdrenghea M, Dima D, Precup R, Tomuleasa C, Soverini S. Assessing Measurable Residual Disease in Chronic Myeloid Leukemia. BCR-ABL1 IS in the Avant-Garde of Molecular Hematology. Front Oncol 2019; 9:863. [PMID: 31608223 PMCID: PMC6768007 DOI: 10.3389/fonc.2019.00863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/20/2019] [Indexed: 11/17/2022] Open
Abstract
Chronic myelogenous leukemia (CML) is a malignancy of the myeloid cell lineage characterized by a recurrent chromosomal abnormality: the Philadelphia chromosome, which results from the reciprocal translocation of the chromosomes 9 and 22. The Philadelphia chromosome contains a fusion gene called BCR-ABL1. The BCR-ABL1 codes for an aberrantly functioning tyrosine kinase that drives the malignant proliferation of the founding clone. The advent of tyrosine kinase inhibitors (TKI) represents a landmark in the treatment of CML, that has led to tremendous improvement in the remission and survival rates. Since the introduction of imatinib, the first TKI, several other TKI have been approved that further broadened the arsenal against CML. Patients treated with TKIs require sensitive monitoring of BCR-ABL1 transcripts with quantitative real-time polymerase chain reaction (qRT-PCT), which has become an essential part of managing patients with CML. In this review, we discuss the importance of the BCR-ABL1 assay, and we highlight the growing importance of BCR-ABL1 dynamics. We also introduce a mathematical correction for the BCR-ABL1 assay that could help homogenizing the use of the ABL1 as a control gene. Finally, we discuss the growing body of evidence concerning treatment-free remission. Along with the continuous improvement in the therapeutic arsenal against CML, the molecular monitoring of CML represents the avant-garde in the struggle to make CML a curable disease.
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Affiliation(s)
- Vlad Moisoiu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
| | - Lorand Parajdi
- Department of Mathematics, Babes Bolyai University, Cluj Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
| | - Radu Precup
- Department of Mathematics, Babes Bolyai University, Cluj Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
- Department of Hematology, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology L. and A. Seràgnoli, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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23
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Cortes J, Huynh L, Mendelson E, Brandt P, Dalal D, DerSarkissian M, Cortina D, Narkhede S, Sheng Duh M. Treatment patterns and deep molecular response in chronic phase - chronic myeloid leukemia patients treated with second-line nilotinib or dasatinib: a multi-country retrospective chart review study. Leuk Lymphoma 2019; 61:98-107. [PMID: 31409168 DOI: 10.1080/10428194.2019.1644332] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Achievement of MR4.5 (BCR-ABL1 ≤ 0.0032% on international scale) is an important goal of tyrosine kinase inhibitor (TKI) treatment for patients with chronic myeloid leukemia (CML). This study describes treatment patterns by region and assesses time to achieve MR4.5 in patients with CML - chronic phase (CP) treated with second-line nilotinib or dasatinib in 10 countries. A multivariate Cox proportional hazards model was used to assess time to MR4.5 for nilotinib versus dasatinib. The model accounted for the competing-risk event of TKI resistance, included random effects for country clustering, and was adjusted for baseline covariates. The study included 280 patients treated with either nilotinib (N = 135 [48%]) or dasatinib (N = 145 [52%]) as second-line TKI with median treatment durations of 19.1 and 18.7 months, respectively. Nilotinib was observed to be better in achieving MR4.5 than dasatinib (adjusted hazard ratio = 1.37, 95% CI [1.11, 1.69]) suggesting second-line nilotinib may perform better in achieving MR4.5 than dasatinib.
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Affiliation(s)
- Jorge Cortes
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - Darshan Dalal
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Diego Cortina
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Sahil Narkhede
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Xu H, Wang P, Ma RJ, Guo JM, Lei PC, Zang YZ, Wang TB, Liu ZW, Yang J, Zhang Y, Zhu ZM. [Comparative study of molecular response of first-line and second-line nilotinib in patients with chronic-phase chronic myelogenous leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:522-525. [PMID: 31340628 PMCID: PMC7342397 DOI: 10.3760/cma.j.issn.0253-2727.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- H Xu
- Jinzhou Medical University, Jinzhou 121001, China; Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - P Wang
- Hematology of Department, Xinyang Central Hospital, Xinyang 464000, China
| | - R J Ma
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - J M Guo
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - P C Lei
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Y Z Zang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - T B Wang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Z W Liu
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - J Yang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Y Zhang
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China
| | - Z M Zhu
- Hematology of Department, Henan Province People's Hospital, Zhengzhou 450003, China; Institute of Hematology, Henan Province People's Hospital, Zhengzhou 450003, China
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25
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Kunbaz A, Eskazan AE. An alternative way – tyrosine kinase inhibitor (TKI) de-escalation – to discontinue TKIs in order to achieve treatment-free remission. Expert Rev Hematol 2019; 12:477-480. [DOI: 10.1080/17474086.2019.1623666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ahmad Kunbaz
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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26
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Park JH, Woo YM, Youm EM, Hamad N, Won HH, Naka K, Park EJ, Park JH, Kim HJ, Kim SH, Kim HJ, Ahn JS, Sohn SK, Moon JH, Jung CW, Park S, Lipton JH, Kimura S, Kim JW, Kim DDH. HMGCLL1 is a predictive biomarker for deep molecular response to imatinib therapy in chronic myeloid leukemia. Leukemia 2018; 33:1439-1450. [PMID: 30555164 PMCID: PMC6756062 DOI: 10.1038/s41375-018-0321-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/27/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
Achieving a deep molecular response (DMR) to tyrosine kinase inhibitor (TKI) therapy for chronic myeloid leukemia (CML) remains challenging and at present, there is no biomarker to predict DMR in this setting. Herein, we report that an HMGCLL1 genetic variant located in 6p12.1 can be used as a predictive genetic biomarker for intrinsic sensitivity to imatinib (IM) therapy. We measured DMR rate according to HMGCLL1 variant in a discovery set of CML patients (n = 201) and successfully replicated it in a validation set (n = 270). We also investigated the functional relevance of HMGCLL1 blockade with respect to response to TKI therapy and showed that small interfering RNA mediated blockade of HMGCLL1 isoform 3 results in significant decrease in viability of BCR-ABL1-positive cells including K562, CML-T1 or BaF3 cell lines with or without ABL1 kinase domain mutations such as T315I mutation. Decreased cell viability was also demonstrated in murine CML stem cells and human hematopoietic progenitor cells. RNA sequencing showed that blockade of HMGCLL1 was associated with G0/G1 arrest and the cell cycle. In summary, the HMGCLL1 gene polymorphism is a novel genetic biomarker for intrinsic sensitivity to IM therapy in CML patients that predicts DMR in this setting.
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Affiliation(s)
- Jong-Ho Park
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Young Min Woo
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Emilia Moonkyung Youm
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Hong-Hee Won
- Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
| | - Kazuhito Naka
- Department of Stem Cell Biology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Eun-Ju Park
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - June-Hee Park
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun-Hee Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sang Kyun Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Joon Ho Moon
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Chul Won Jung
- Department of Hematology/Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Silvia Park
- Department of Hematology/Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeffrey H Lipton
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Jong-Won Kim
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea. .,Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea. .,Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
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27
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Hernández-Boluda JC, Pereira A, Pastor-Galán I, Alvarez-Larrán A, Savchuk A, Puerta JM, Sánchez-Pina JM, Collado R, Díaz-González A, Angona A, Sagüés M, García-Gutiérrez V, Boqué C, Osorio S, Vallansot R, Palomera L, Mendizábal A, Casado LF, Pérez-Encinas M, Pérez-López R, Ferrer-Marín F, Sánchez-Guijo F, García C, Heras NDL, López-Lorenzo JL, Cervantes F, Steegmann JL. Feasibility of treatment discontinuation in chronic myeloid leukemia in clinical practice: results from a nationwide series of 236 patients. Blood Cancer J 2018; 8:91. [PMID: 30504932 PMCID: PMC6275158 DOI: 10.1038/s41408-018-0125-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/10/2018] [Accepted: 08/17/2018] [Indexed: 12/11/2022] Open
Abstract
Over half of chronic myeloid leukemia (CML) patients in deep molecular response do not lose the major molecular response (MMR) after stopping treatment with tyrosine kinase inhibitors (TKI). This strategy is safe in clinical trials, but its applicability in the real-life setting remains unsettled. We describe the outcomes after TKI discontinuation in a nationwide series of 236 CML patients. Median follow-up from treatment discontinuation was 21.5 months and 5 patients died from CML-unrelated causes. TKI therapy was reinitiated due to MMR loss (n = 52), increase ≥ 1 log in BCR-ABL transcript level without losing MMR (n = 12), patient preference (n = 2), and withdrawal syndrome (n = 1). Treatment-free remission rate at 4 years was 64% (95% confidence interval, CI: 55%–72%). Cumulative incidence of molecular recurrence at 3 years was 33% (95% CI: 26%–38%). TKI treatment for < 5 years and MR4.5 duration shorter than 4 years were both associated with higher incidence of molecular recurrence. No patient had disease progression. Response status at last control was: MR4.5 (n = 196), MR4 (n = 15), MMR (n = 14), complete cytogenetic response (n = 10), and other (n = 1). A significant increase in Hb and cholesterol levels was observed after imatinib withdrawal. Our results demonstrate that TKI treatment discontinuation is feasible in real-life clinical practice.
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Affiliation(s)
| | - Arturo Pereira
- Hemotherapy and Hemostasis Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Irene Pastor-Galán
- Hematology Department, Hospital Clínico Universitario-INCLIVA, Valencia, Spain
| | - Alberto Alvarez-Larrán
- Hematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alisa Savchuk
- Hematology Department, Hospital Universitario La Princesa, Madrid, Spain
| | - José Manuel Puerta
- Hematology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Rosa Collado
- Hematology Department, Hospital General Universitario, Valencia, Spain
| | | | - Anna Angona
- Hematology Department, Hospital del Mar-IMIM, Barcelona, Spain
| | - Miguel Sagüés
- Hematology Department, Hospital Universitario de Girona, Doctor Josep Trueta, Girona, Spain
| | | | - Concepción Boqué
- Hematology Department, Institut Català d'Oncologia, Hospital Duran i Reynals, Hospitalet de Llobregat, Spain
| | - Santiago Osorio
- Hematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rolando Vallansot
- Hematology Department, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Luis Palomera
- Hematology Department, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | | | | | - Manuel Pérez-Encinas
- Hematology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Raúl Pérez-López
- Hematology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francisca Ferrer-Marín
- Hematology and Medical Oncology Department, Hospital Morales Meseguer-CIBERER, IMIB-Arrixaca, UCAM, Murcia, Spain
| | - Fermín Sánchez-Guijo
- Hematology Department, Hospital Universitario de Salamanca, IBSAL, Salamanca, Spain
| | - Carmen García
- Hematology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | - Francisco Cervantes
- Hematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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28
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Fu Y, Zhang R, Wu Q, Zhang J, Bao L, Li J. External quality assessment of p210 BCR-ABL1 transcript quantification by RT-qPCR: Findings and recommendations. Int J Lab Hematol 2018; 41:46-54. [PMID: 30203581 DOI: 10.1111/ijlh.12919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION External quality assessment (EQA) is an essential tool for quality assurance of analytical testing processes of p210 BCR-ABL1 transcripts by RT-qPCR. As an EQA provider, the National Center for Clinical Laboratories organized an EQA scheme of p210 BCR-ABL1 testing in China for the first time to identify existing problems and ensure the reliability of p210 BCR-ABL1 testing. METHODS Using armored RNA technology, we first constructed pACYC-MS2-p210 and CG recombinant plasmids and expressed p210 and CG armored RNAs, with packaging segments of p210 BCR-ABL1 fusion gene (FG) and four common control gene (CG) transcripts. Using these armored RNAs, we prepared lyophilized p210 quality control (QC) sample panels and evaluated detection performance of participating laboratories in China. RESULTS Of the 66 participating laboratories, great variation was found with coefficient of variation (CV%) of raw p210 BCR-ABL1 results basically ranging from 60.0% to 100.0%. In 24 International Scale (IS) laboratories, the CV% of results decreased from 82.4% to 61.6%, and the percentage of laboratories within 2-, 3-, and 5-fold of the median values increased from 78.2%, 87.0%, and 92.1% to 80.1%, 89.4%, and 97.2%, respectively, after conversion with a laboratory-specific conversion factor (CF); however, poorly converted results were also observed in laboratories resulting from changed components of RT-qPCR procedures. False-negative and false-positive results were also found in the EQA. CONCLUSIONS Various problems were found for p210 BCR-ABL1 detection in the EQA. By solving the existing problems, the performance of p210 BCR-ABL1 detection can be improved, ensuring robust laboratory diagnostic capacities in China.
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Affiliation(s)
- Yu Fu
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Rui Zhang
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Qisheng Wu
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Jiawei Zhang
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
| | - Lihua Bao
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinming Li
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, China
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29
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Schmitt MW, Pritchard JR, Leighow SM, Aminov BI, Beppu L, Kim DS, Hodgson JG, Rivera VM, Loeb LA, Radich JP. Single-Molecule Sequencing Reveals Patterns of Preexisting Drug Resistance That Suggest Treatment Strategies in Philadelphia-Positive Leukemias. Clin Cancer Res 2018; 24:5321-5334. [PMID: 30042204 DOI: 10.1158/1078-0432.ccr-18-0167] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/28/2018] [Accepted: 07/17/2018] [Indexed: 11/16/2022]
Abstract
Purpose: Sequential treatment with targeted therapies can result in complex combinations of resistance mutations in drug targets. This mutational complexity has spurred the development of pan-target inhibitors, i.e., therapies for which no single target mutation can cause resistance. Because the propensity for on- versus off-target resistance varies across cancer types, a deeper understanding of the mutational burden in drug targets could rationalize treatment outcomes and prioritize pan-target inhibitors for indications where on-target mutations are most likely.Experimental Design: To measure and model the mutational landscape of a drug target at high resolution, we integrated single-molecule Duplex Sequencing of the ABL1 gene in Philadelphia-positive (Ph+) leukemias with computational simulations.Results: A combination of drug target mutational burden and tumor-initiating cell fraction is sufficient to predict that most patients with chronic myeloid leukemia are unlikely to harbor ABL1 resistance mutations at the time of diagnosis, rationalizing the exceptional success of targeted therapy in this setting. In contrast, our analysis predicts that many patients with Ph+ acute lymphoblastic leukemia (Ph+ ALL) harbor multiple preexisting resistant cells with single mutants. The emergence of compound mutations can be traced to initial use of an ABL1 inhibitor that is susceptible to resistance from single point mutations.Conclusions: These results argue that early use of therapies that achieve pan-inhibition of ABL1 resistance mutants might improve outcomes in Ph+ ALL. Our findings show how a deep understanding of the mutational burden in drug targets can be quantitatively coupled to phenotypic heterogeneity to rationalize clinical phenomena. Clin Cancer Res; 24(21); 5321-34. ©2018 AACR.
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Affiliation(s)
- Michael W Schmitt
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Justin R Pritchard
- ARIAD Pharmaceuticals, Cambridge, Massachusetts. .,Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania
| | - Scott M Leighow
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, Pennsylvania
| | - Bella I Aminov
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Lan Beppu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel S Kim
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | | | | | - Lawrence A Loeb
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Jerald P Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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30
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Pagani IS, Dang P, Kommers IO, Goyne JM, Nicola M, Saunders VA, Braley J, White DL, Yeung DT, Branford S, Hughes TP, Ross DM. BCR-ABL1 genomic DNA PCR response kinetics during first-line imatinib treatment of chronic myeloid leukemia. Haematologica 2018; 103:2026-2032. [PMID: 29976745 PMCID: PMC6269287 DOI: 10.3324/haematol.2018.189787] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
Accurate quantification of minimal residual disease (MRD) during treatment of chronic myeloid leukemia (CML) guides clinical decisions. The conventional MRD method, RQ-PCR for BCR-ABL1 mRNA, reflects a composite of the number of circulating leukemic cells and the BCR-ABL1 transcripts per cell. BCR-ABL1 genomic DNA only reflects leukemic cell number. We used both methods in parallel to determine the relative contribution of the leukemic cell number to molecular response. BCR-ABL1 DNA PCR and RQ-PCR were monitored up to 24 months in 516 paired samples from 59 newly-diagnosed patients treated with first-line imatinib in the TIDEL-II study. In the first three months of treatment, BCR-ABL1 mRNA values declined more rapidly than DNA. By six months, the two measures aligned closely. The expression of BCR-ABL1 mRNA was normalized to cell number to generate an expression ratio. The expression of e13a2 BCR-ABL1 was lower than that of e14a2 transcripts at multiple time points during treatment. BCR-ABL1 DNA was quantifiable in 48% of samples with undetectable BCR-ABL1 mRNA, resulting in MRD being quantifiable for an additional 5-18 months (median 12 months). These parallel studies show for the first time that the rapid decline in BCR-ABL1 mRNA over the first three months of treatment is due to a reduction in both cell number and transcript level per cell, whereas beyond three months, falling levels of BCR-ABL1 mRNA are proportional to the depletion of leukemic cells.
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Affiliation(s)
- Ilaria S Pagani
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia
| | - Phuong Dang
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Ivar O Kommers
- VU University Medical Center, Amsterdam, the Netherlands
| | - Jarrad M Goyne
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Mario Nicola
- Genetic and Molecular Pathology, SA Pathology, Adelaide, Australia
| | - Verity A Saunders
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Jodi Braley
- Genetic and Molecular Pathology, SA Pathology, Adelaide, Australia
| | - Deborah L White
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia.,School of Biological Sciences, Faculty of Sciences, University of Adelaide, Australia.,School of Paediatrics, Faculty of Health Sciences, University of Adelaide, Australia.,Health Sciences UniSA, Adelaide, Australia
| | - David T Yeung
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia.,Australasian Leukaemia and Lymphoma Group, Melbourne, Australia.,Department of Haematology, Royal Adelaide Hospital and SA Pathology, Australia
| | - Susan Branford
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia.,Genetic and Molecular Pathology, SA Pathology, Adelaide, Australia.,School of Paediatrics, Faculty of Health Sciences, University of Adelaide, Australia.,Centre for Cancer Biology, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
| | - Timothy P Hughes
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia.,Australasian Leukaemia and Lymphoma Group, Melbourne, Australia.,Department of Haematology, Royal Adelaide Hospital and SA Pathology, Australia.,Centre for Cancer Biology, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia
| | - David M Ross
- Cancer Theme, South Australian Health & Medical Research Institute, Adelaide, Australia .,School of Medicine, Faculty of Health Sciences, University of Adelaide, Australia.,Australasian Leukaemia and Lymphoma Group, Melbourne, Australia.,Department of Haematology, Royal Adelaide Hospital and SA Pathology, Australia.,Centre for Cancer Biology, School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia.,Flinders University and Medical Centre, Adelaide, Australia
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Improving Outcomes in Chronic Myeloid Leukemia Over Time in the Era of Tyrosine Kinase Inhibitors. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:710-723. [PMID: 30093283 DOI: 10.1016/j.clml.2018.06.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/20/2018] [Accepted: 06/28/2018] [Indexed: 12/21/2022]
Abstract
Most patients with chronic myeloid leukemia (CML) receiving treatment with BCR-ABL1 tyrosine kinase inhibitors (TKIs) will achieve favorable responses. Moreover, TKI therapy enables patients to experience long-term survival, with survival rates similar to those of individuals without CML. This enhanced survival has resulted from the availability of multiple BCR-ABL1 TKIs with efficacy, not only in frontline treatment, but, importantly, also in second- and third-line treatment. We have reviewed the changes in long-term outcomes in the era of TKI therapy and how these changes have affected treatment practices. We discuss the development of imatinib, the first BCR-ABL1 TKI, followed by newer TKIs, including nilotinib, dasatinib, bosutinib, and ponatinib. We consider the key studies that led to their development as frontline or later-line therapies, their safety profiles, and their effect on improving patient outcomes. With these improved outcomes, the definition of an optimal response has become more stringent, and treatment monitoring strategies have changed. Second-line patient populations have evolved from those with resistance to, or intolerance of, imatinib to those with moderate responses to, or low-grade adverse events with, imatinib. Although all TKIs are associated with high survival rates, newer TKIs have been associated with lower disease progression rates and, importantly, deeper treatment responses and, potentially, a greater chance of future treatment-free remission. Finally, we consider the unmet needs of patients with CML, including the challenges remaining for those without optimal responses during TKI therapy and new therapies and strategies to identify such patients at diagnosis.
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Abstract
Strict criteria for when to stop tyrosine kinase inhibitor (TKI) therapy in clinical practice are not easily defined without an agreement on what probability of achieving a treatment-free remission (TFR) constitutes a medically acceptable standard and consideration of the potential medical risks of continued TKI therapy and/or patient preferences. Patients in sustained deep molecular response (DMR) have no significant chronic myelogenous leukemia-related risk of progression and death, and thus, safety is of paramount importance. Patients with prior history of advanced disease, additional chromosomal abnormalities (ACA), atypical transcripts, TKI resistance, high Sokal score, or who cannot be relied upon to come for regular molecular monitoring should generally be excluded from TKI cessation in clinical practice. Similarly, stopping TKIs should not be attempted without the availability of standardized BCR-ABL1 testing with a sensitivity of at least MR4.5 and a turnaround time of less than 4 weeks. Prior TKI therapy of 5 years and stable MR4.0 of 2 years or more constitutes reasonable minimal criteria for stopping TKIs with approximately a 50% chance of success. The risk of morbidity with continued TKI therapy and patient preferences need to be considered to determine to what extent these minimal criteria should be exceeded and at what threshold to re-initiate therapy whether on the loss of major molecular response or at a lower molecular endpoint.
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Efficacy and safety of nilotinib 300 mg twice daily in patients with chronic myeloid leukemia in chronic phase who are intolerant to prior tyrosine kinase inhibitors: Results from the Phase IIIb ENESTswift study. Leuk Res 2018; 67:109-115. [PMID: 29494928 DOI: 10.1016/j.leukres.2018.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Some patients receiving a tyrosine kinase inhibitor (TKI) for the first-line treatment of chronic phase chronic myeloid leukemia (CML-CP) experience intolerable adverse events. Management strategies include dose adjustments, interrupting or discontinuing therapy, or switching to an alternative TKI. METHODS This multicenter, single-arm, Phase IIIb study included CML-CP patients intolerant of, but responsive to, first-line treatment with imatinib or dasatinib. All patients were switched to nilotinib 300 mg bid for up to 24 months. The primary endpoint was achievement of MR4.5 (BCR-ABL transcript level of ≤0.0032% on the International Scale) by 24 months. RESULTS Twenty patients were enrolled in the study (16 imatinib-intolerant, 4 dasatinib-intolerant); which was halted early because of low recruitment. After the switch to nilotinib 300 mg bid, MR4.5 at any time point up to month 24 was achieved in 10 of 20 patients (50%) in the full analysis set. Of the non-hematological adverse events associated with intolerance to prior imatinib or dasatinib, 74% resolved within 12 weeks of switching to nilotinib 300 mg bid. CONCLUSION Nilotinib 300 mg bid shows minimal cross intolerance in patients with CML-CP who have prior toxicities to other TKIs and can lead to deep molecular responses.
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TKI rotation-induced persistent deep molecular response in multi-resistant blast crisis of Ph+ CML. Oncotarget 2018; 8:23061-23072. [PMID: 28416739 PMCID: PMC5410285 DOI: 10.18632/oncotarget.15481] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/07/2017] [Indexed: 12/29/2022] Open
Abstract
In chronic myeloid leukemia (CML) resistance against one or more BCR-ABL1 tyrosine kinase inhibitors (TKI) remains a clinical challenge. Preclinical data suggest that TKI combinations may overcome resistance. We report on a heavily pre-treated 78 year-old female patient with CML who developed multi-resistant blast crisis with bone marrow fibrosis and a Ph- clone. Treatment with ponatinib resulted in blast cell clearance, decrease in fibrosis, and disappearance of BCR-ABL1, but also in severe thrombocytopenia with bleedings requiring platelet transfusions. We therefore switched from ponatinib to bosutinib. During bosutinib, platelet counts recovered. However, after 6 months, BCR-ABL1 mRNA levels increased to > 1%. Therefore, we ´switched back´ to ponatinib, and this was again followed by disappearance of BCR-ABL1 and a decrease in platelets. During the next 2 years, we applied ponatinib and bosutinib in continuous rotation-cycles and added hydroxyurea in order to suppress all sub-clones and to balance between efficacy and potential side effects following the principle of personalized medicine. With this approach the patient remained in complete molecular response and reached normal blood counts and a normal quality of life without vascular or other side effects. In conclusion, TKI rotation is a novel potent approach to suppress multiple resistant sub-clones and to balance between clinical efficacy and side effects in patients with advanced CML. Clinical trials are now warranted to show that TKI-rotation is in general safe and effective in these patients.
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Chen KK, Du TF, Wu KS, Yang W. First-line treatment strategies for newly diagnosed chronic myeloid leukemia: a network meta-analysis. Cancer Manag Res 2018; 10:3891-3910. [PMID: 30288121 PMCID: PMC6163008 DOI: 10.2147/cmar.s177566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES With bosutinib proven to be available for frontline treatment, there are currently four frontline treatments as well as an additional strategy with high-dose imatinib for newly diagnosed chronic myeloid leukemia (CML). Due to the lack of direct comparison of high-dose imatinib, dasatinib, nilotinib, and bosutinib, we summarized the evidence to indirectly compare the efficacy among these treatment options. METHODS In total, 14 randomized clinical trials including 5,630 patients were analyzed by direct and mixed-treatment comparisons. Outcomes assessed were the following: complete cytogenetic response at 12 months; major molecular response at 12, 24, and 36 months; deep molecular response at 12, 24, 36, and 60 months; early molecular response at 3 months; progression-free survival (PFS); overall survival (OS); and Grade 3 or 4 adverse events (AEs). RESULTS The Bayesian network meta-analysis demonstrated that high-dose imatinib was less effective than all new-generation tyrosine kinase inhibitors and had a higher probability of Grade 3 or 4 AEs. For molecular response, 300 mg of nilotinib was likely to be the preferred frontline treatment, as demonstrated by higher response rates and faster, deeper, and longer molecular response. For PFS and OS, there were high likelihoods (79% and 74%, respectively) that 400 mg of nilotinib was the preferred option. For AEs, standard-dose imatinib has the highest probability (65%) of being the most favorable toxicity profile. CONCLUSION Considering the efficacy and toxicity profile, it is not recommended to use high-dose imatinib for treatment. This analysis also showed that nilotinib has the highest probability to become the preferred frontline agents for treating CML.
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Affiliation(s)
- Kang-Kang Chen
- Department of Preventive Medicine and MPH Education Center, Shantou University Medical College, Shantou, Guangdong Province, China
| | - Tai-Feng Du
- Department of Preventive Medicine and MPH Education Center, Shantou University Medical College, Shantou, Guangdong Province, China
| | - Ku-Sheng Wu
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong Province, China
| | - Wei Yang
- Department of Thoracic Surgery, Administrative Office, Shantou University Medical College Cancer Hospital, Shantou, Guangdong Province, China,
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36
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Landberg N, von Palffy S, Askmyr M, Lilljebjörn H, Sandén C, Rissler M, Mustjoki S, Hjorth-Hansen H, Richter J, Ågerstam H, Järås M, Fioretos T. CD36 defines primitive chronic myeloid leukemia cells less responsive to imatinib but vulnerable to antibody-based therapeutic targeting. Haematologica 2017; 103:447-455. [PMID: 29284680 PMCID: PMC5830390 DOI: 10.3324/haematol.2017.169946] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are highly effective for the treatment of chronic myeloid leukemia (CML), but very few patients are cured. The major drawbacks regarding TKIs are their low efficacy in eradicating the leukemic stem cells responsible for disease maintenance and relapse upon drug cessation. Herein, we performed ribonucleic acid sequencing of flow-sorted primitive (CD34+CD38low) and progenitor (CD34+ CD38+) chronic phase CML cells, and identified transcriptional upregulation of 32 cell surface molecules relative to corresponding normal bone marrow cells. Focusing on novel markers with increased expression on primitive CML cells, we confirmed upregulation of the scavenger receptor CD36 and the leptin receptor by flow cytometry. We also delineate a subpopulation of primitive CML cells expressing CD36 that is less sensitive to imatinib treatment. Using CD36 targeting antibodies, we show that the CD36 positive cells can be targeted and killed by antibody-dependent cellular cytotoxicity. In summary, CD36 defines a subpopulation of primitive CML cells with decreased imatinib sensitivity that can be effectively targeted and killed using an anti-CD36 antibody.
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Affiliation(s)
- Niklas Landberg
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Sofia von Palffy
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Maria Askmyr
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Henrik Lilljebjörn
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Carl Sandén
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Marianne Rissler
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Satu Mustjoki
- Hematology Research Unit Helsinki, Department of Clinical Chemistry and Hematology, University of Helsinki, and Helsinki University Hospital Comprehensive Cancer Center, Finland
| | | | - Johan Richter
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Helena Ågerstam
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Marcus Järås
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
| | - Thoas Fioretos
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Sweden
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37
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Lasorella A, Sanson M, Iavarone A. FGFR-TACC gene fusions in human glioma. Neuro Oncol 2017; 19:475-483. [PMID: 27852792 PMCID: PMC5464372 DOI: 10.1093/neuonc/now240] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/12/2016] [Indexed: 12/30/2022] Open
Abstract
Chromosomal translocations joining in-frame members of the fibroblast growth factor receptor-transforming acidic coiled-coil gene families (the FGFR-TACC gene fusions) were first discovered in human glioblastoma multiforme (GBM) and later in many other cancer types. Here, we review this rapidly expanding field of research and discuss the unique biological and clinical features conferred to isocitrate dehydrogenase wild-type glioma cells by FGFR-TACC fusions. FGFR-TACC fusions generate powerful oncogenes that combine growth-promoting effects with aneuploidy through the activation of as yet unclear intracellular signaling mechanisms. FGFR-TACC fusions appear to be clonal tumor-initiating events that confer strong sensitivity to FGFR tyrosine kinase inhibitors. Screening assays have recently been reported for the accurate identification of FGFR-TACC fusion variants in human cancer, and early clinical data have shown promising effects in cancer patients harboring FGFR-TACC fusions and treated with FGFR inhibitors. Thus, FGFR-TACC gene fusions provide a "low-hanging fruit" model for the validation of precision medicine paradigms in human GBM.
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Affiliation(s)
- Anna Lasorella
- Institute for Cancer Genetics, Department of Pediatrics and Pathology, Columbia University Medical Center, New York, New York, USA
| | - Marc Sanson
- Sorbonne Universités UPMC Univ Paris 06, INSERM CNRS, U1127, UMR 7225, ICM, F-75013,Groupe Hospitalier Pitié-Salpêtrière, Service de Neurologie 2, Paris, France
| | - Antonio Iavarone
- Institute for Cancer Genetics, Department of Neurology and Pathology, Columbia University Medical Center, New York, New York, USA
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CML patients with deep molecular responses to TKI have restored immune effectors and decreased PD-1 and immune suppressors. Blood 2017; 129:1166-1176. [DOI: 10.1182/blood-2016-10-745992] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 12/17/2016] [Indexed: 12/12/2022] Open
Abstract
Key Points
Increased immune suppressors and PD-1 abrogates effector responses in CML patients at diagnosis. Enhanced net effector immune responses and decreased PD-1 and immune suppressors may promote sustained deep molecular response in CML.
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39
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Manley PW, Stiefl NJ. Progress in the Discovery of BCR-ABL Kinase Inhibitors for the Treatment of Leukemia. TOPICS IN MEDICINAL CHEMISTRY 2017. [DOI: 10.1007/7355_2017_5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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40
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Branford S. Molecular monitoring in chronic myeloid leukemia-how low can you go? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:156-163. [PMID: 27913475 PMCID: PMC6142476 DOI: 10.1182/asheducation-2016.1.156] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Molecular monitoring of BCR-ABL1 transcripts for patients with chronic myeloid leukemia (CML) is now used to assess response to tyrosine kinase inhibitors (TKIs), including treatment failure that mandates a change of therapy. Therefore, many centers have adopted the molecular technique for measuring BCR-ABL1 and rely on conversion of values to the international reporting scale for appropriate clinical interpretation. However, the technique has a degree of inherent variability despite standardized procedures, which means care should be taken by the clinician when assessing response based on BCR-ABL1 cutoff limits. The last few years have witnessed the emergence of a new molecular response target, which is the achievement and maintenance of a deep molecular response. The ability to achieve treatment-free remission for some patients has shifted the relevant boundary for molecular response. However, the definitive safe BCR-ABL1 transcript level and length of the maintenance phase after which treatment cessation can be attempted has not yet been determined. For patients with TKI resistance, BCR-ABL1 kinase domain mutation analysis remains an essential assessment to guide therapy. Furthermore, low-level mutation detection is clinically relevant for response prediction to subsequent TKI therapy for some patients. Multiple low-level mutations may be a biomarker of a clonally diverse disease with the propensity for resistance evolution. Overall, molecular monitoring, including low-level monitoring is a fundamental component of management for patients with CML.
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MESH Headings
- Drug Resistance, Neoplasm
- Fusion Proteins, bcr-abl/blood
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Protein Kinase Inhibitors/therapeutic use
- RNA, Messenger/blood
- RNA, Messenger/genetics
- RNA, Neoplasm/blood
- RNA, Neoplasm/genetics
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Affiliation(s)
- Susan Branford
- 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; School of Medicine; and School of Molecular and Biomedical Science, University of Adelaide, Adelaide, Australia
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Qin YZ, Jiang Q, Lai YY, Jiang H, Shi HX, Zhao XS, Liu YR, Huang XJ. Concordant optimal molecular and cytogenetic responses at both 3 and 6 months predict a higher probability of MR4.5 achievement in patients with chronic myeloid leukemia treated with imatinib. Leuk Lymphoma 2016; 58:1384-1393. [PMID: 27733081 DOI: 10.1080/10428194.2016.1239260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To investigate the impact of the combination of early molecular and cytogenetic responses on the achievement of MR4.5, 228 newly diagnosed chronic phase chronic myeloid leukemia patients treated with imatinib were categorized into 3-month and 6-month concordant optimal, discordant, concordant warning, and failure groups. Among them, 85.3% at 3 months and 78.1% at 6 months had concordant molecularly and cytogenetically defined responses. At both 3 and 6 months, patients with discordant, concordant warning and failure responses had similar 3-year MR4.5 rates, and all were significantly lower than the rate in patients with concordant optimal responses. Patients with concurrent 3-month and 6-month concordant optimal responses had a significantly higher 3-year MR4.5 rate than those with other responses, and 3-month and 6-month concurrent molecular optimal, but not cytogenetic optimal responses. Therefore, achieving concordant optimal molecular and cytogenetic responses at both 3 and 6 months with imatinib treatment are associated with MR4.5 achievement.
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Affiliation(s)
- Ya-Zhen Qin
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Qian Jiang
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Yue-Yun Lai
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Hao Jiang
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Hong-Xia Shi
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Xiao-Su Zhao
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Yan-Rong Liu
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China
| | - Xiao-Jun Huang
- a Peking University People's Hospital, Peking University Institute of Hematology , Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation , Beijing , China.,b Peking-Tsinghua Center for Life Sciences , Beijing , China
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Saydam G, Haznedaroglu IC, Kaynar L, Yavuz AS, Ali R, Guvenc B, Akay OM, Baslar Z, Ozbek U, Sonmez M, Aydin D, Pehlivan M, Undar B, Dagdas S, Ayyildiz O, Akkaynak DZ, Dag IM, Ilhan O. Outcomes with frontline nilotinib treatment in Turkish patients with newly diagnosed Philadelphia chromosome–positive chronic myeloid leukemia in chronic phase. Expert Opin Pharmacother 2016; 17:1851-8. [DOI: 10.1080/14656566.2016.1219338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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43
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Caldemeyer L, Akard LP. Rationale and motivating factors for treatment-free remission in chronic myeloid leukemia. Leuk Lymphoma 2016; 57:2739-2751. [DOI: 10.1080/10428194.2016.1198959] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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44
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Arora R, Press RD. Measurement of BCR-ABL1 transcripts on the International Scale in the United States: current status and best practices. Leuk Lymphoma 2016; 58:8-16. [PMID: 27412040 DOI: 10.1080/10428194.2016.1190974] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic myeloid leukemia (CML) results from the Philadelphia chromosome (Ph) translocation and expression of its fusion oncoprotein BCR-ABL1. BCR-ABL1 tyrosine kinase inhibitors (TKIs) are the standard therapy for Ph-positive CML. Achievement of deep molecular responses (typically defined as ≥4-log reduction in BCR-ABL1 RNA levels) is an emerging treatment goal becoming attainable for more patients due to the availability of second-generation TKIs. Deep molecular responses are associated with improved long-term outcomes and are required prior to attempting cessation of treatment in treatment-free remission clinical trials. The National Comprehensive Cancer Network and European LeukemiaNet recommend regular monitoring of BCR-ABL1 RNA levels using real-time quantitative polymerase chain reaction (RQ-PCR). However, BCR-ABL1 RQ-PCR is a complex laboratory-developed test; routine quantitative results from clinical diagnostic laboratories may differ from those used to establish the recommendations. Although an International Scale (IS) was developed for standardized reporting of BCR-ABL1 RNA levels, IS adoption has been slow in the United States, but is now used by the vast majority of laboratories. Here, we discuss the importance of molecular monitoring in CML, gaps between current and best molecular monitoring practices in the United States, and challenges and potential solutions for universal IS adoption in the United States.
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Affiliation(s)
- Ranjana Arora
- a Department of Pathology and Laboratory Medicine , University of Kentucky , Lexington , KY , USA
| | - Richard D Press
- b Department of Pathology and Knight Cancer Institute , Oregon Health & Science University , Portland , OR , USA
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45
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Sweet K, Pinilla-Ibarz J. Early switch in tyrosine kinase inhibitor therapy for patients with chronic myeloid leukemia: An emerging clinical question. Crit Rev Oncol Hematol 2016; 103:99-108. [DOI: 10.1016/j.critrevonc.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 03/29/2016] [Accepted: 05/12/2016] [Indexed: 01/09/2023] Open
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46
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Bhalla S, Tremblay D, Mascarenhas J. Discontinuing Tyrosine Kinase Inhibitor Therapy in Chronic Myelogenous Leukemia: Current Understanding and Future Directions. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:488-494. [PMID: 27406834 DOI: 10.1016/j.clml.2016.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/11/2016] [Accepted: 06/01/2016] [Indexed: 11/29/2022]
Abstract
BCR-ABL1 tyrosine kinase inhibitors (TKIs) have dramatically transformed the treatment of patients with chronic myelogenous leukemia (CML). Given the impressive and sustained response to TKI therapy that the majority of treated patients with CML enjoy, recent studies have explored the potential to achieve treatment-free remission in select patients, which may allow these patients to escape the adverse clinical and financial effects associated with life-long TKI therapy. The results of multiple prospective trials have demonstrated that patients who maintain a deep molecular response for at least 2 years with TKI treatment may be eligible for trial of TKI discontinuation. Mounting data indicates that approximately 40% of those who discontinue therapy on trial will remain in remission at least 1 year after TKI discontinuation; the majority of patients with molecular recurrence relapse within the first 6 months after TKI discontinuation, and TKI retreatment is highly effective in restoring response. Sokol score, duration of TKI therapy, depth of molecular response, and the presence of natural killer cells may all be associated with a higher probability of attaining treatment-free remission. Moving forward, emerging data from ongoing TKI discontinuation trials will allow for appropriate selection of patients with CML eligible for this approach, will expand our current understanding of the CML stem cell, and identify therapeutic interventions capable of effectively deleting the malignant hematopoietic stem cell.
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Affiliation(s)
- Sheena Bhalla
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas Tremblay
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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Etienne G, Huguet F, Guerci-Bresler A, Nicolini FE, Maloisel F, Coiteux V, Dauriac C, Carpentier N, Bourdeix I, Tulliez M, Cony-Makhoul P. Impact of ELN recommendations in the management of first-line treated chronic myeloid leukaemia patients: a French cross-sectional study. Br J Haematol 2016; 174:71-80. [PMID: 27060881 DOI: 10.1111/bjh.14022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/12/2016] [Indexed: 11/28/2022]
Abstract
The availability of tyrosine kinase inhibitors has extended therapeutic options for chronic myeloid leukaemia (CML) patients. Monitoring recommendations and clinical response goals have recently been updated. The objective of this study was to describe the profile of CML patients in chronic phase currently receiving first-line therapy, including treatment, monitoring and response kinetics. A multicentre, cross-sectional, epidemiological survey in unselected chronic phase CML patients in France attending consultations during a one-month period was performed. 438 of 697 (62·8%) reported patients were currently receiving first-line treatment and were analysed. Imatinib was the most frequently received treatment (72·4% of patients). Retrospective cytogenetic and molecular assessments at 3, 6, 12 or 18 months were available in 88·4% of patients. At the 12-month assessment, 32·2% were not in major molecular response (MMR). At last assessment, among 355 patients with duration of treatment ≥ 12 months, 91·5% had achieved MMR and 66·5% were in deep molecular response. This study, performed in everyday practice population of CML patients, suggests that monitoring of molecular responses in real-life practice is aligned with European LeukaemiaNet recommendations. The majority of patients still receiving first-line treatment are in optimal response, with a few being classified as in the warning area or responding to failure.
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Soverini S, De Benedittis C, Mancini M, Martinelli G. Best Practices in Chronic Myeloid Leukemia Monitoring and Management. Oncologist 2016; 21:626-33. [PMID: 27032870 DOI: 10.1634/theoncologist.2015-0337] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/21/2016] [Indexed: 12/24/2022] Open
Abstract
UNLABELLED : Optimal use of current therapeutic opportunities for chronic myeloid leukemia patients requires integration of clinical and laboratory monitoring. Assessment of molecular response (MR) by real-time quantitative polymerase chain reaction is the most sensitive way to monitor tyrosine kinase inhibitor (TKI) treatment efficacy. Besides major molecular response, which has emerged as a safe haven for survival since the initial studies of first-line imatinib treatment, two additional MR milestones have recently been defined: early molecular response and deep molecular response. The achievement of such MR milestones within defined time points during therapy is thought to draw the ideal trajectory toward optimal long-term outcome and, possibly, successful treatment discontinuation. Sensitive and reproducible MR measurement and proper interpretation of MR results are therefore critical to correctly inform therapeutic decisions. In patients who do not achieve an optimal response to TKI therapy, BCR-ABL1 mutation screening should also be performed, because it may deliver useful information for TKI choice. This review aims to help clinicians apply and translate the latest response definitions and clinical recommendations into practice. We provide a critical update on how these recommendations have incorporated MR levels in the clinical decision algorithms and how detection of BCR-ABL1 mutations should be interpreted. We also include a practical guide for pathologists and molecular biologists to best perform molecular testing and for hematologists and oncologists to best integrate it into routine practice. IMPLICATIONS FOR PRACTICE Ever-more-potent therapeutic strategies have been developed for chronic myeloid leukemia (CML) in parallel with the evolution of therapeutic goals and the refinement of response definitions and monitoring schemes and procedures. Terminology and methodology continue to evolve rapidly, making it difficult for busy hematology/oncology professionals to keep abreast of the newest developments. Optimal CML patient management results from the timely and rational use of molecular testing, the critical assessment of the power and pitfalls of current technology, and the appropriate interpretation and contextualization of results.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Caterina De Benedittis
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology "L. e A. Seràgnoli," University of Bologna, Bologna, Italy
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Soverini S, De Benedittis C, Mancini M, Martinelli G. Present and future of molecular monitoring in chronic myeloid leukaemia. Br J Haematol 2016; 173:337-49. [PMID: 26947577 DOI: 10.1111/bjh.13966] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Currently, physicians treating chronic myeloid leukaemia (CML) patients can rely on a wide spectrum of therapeutic options: the best use of such options is essential to achieve excellent clinical outcomes and, possibly, treatment-free remission (TFR). To accomplish this, proper integration of expert clinical and laboratory monitoring of CML patients is fundamental. Molecular response (MR) monitoring of patients at defined time points has emerged as an important success factor for optimal disease management and BCR-ABL1 kinase domain mutation screening is useful to guide therapeutic reassessment in patients who do not achieve optimal responses to tyrosine kinase inhibitor therapy. Deeper MRs might be associated with improved long-term survival outcomes. More importantly, they are considered a gateway to TFR. In molecular biology, novel procedures and technologies are continually being developed. More sophisticated molecular tools and automated analytical solutions are emerging as CML treatment endpoints and expectations become more and more ambitious. Here we provide a critical overview of current and novel methodologies, present their strengths and pitfalls and discuss what their present and future role might be.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Caterina De Benedittis
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
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50
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Padula WV, Larson RA, Dusetzina SB, Apperley JF, Hehlmann R, Baccarani M, Eigendorff E, Guilhot J, Guilhot F, Hehlmann R, Mahon FX, Martinelli G, Mayer J, Müller MC, Niederwieser D, Saussele S, Schiffer CA, Silver RT, Simonsson B, Conti RM. Cost-effectiveness of Tyrosine Kinase Inhibitor Treatment Strategies for Chronic Myeloid Leukemia in Chronic Phase After Generic Entry of Imatinib in the United States. J Natl Cancer Inst 2016; 108:djw003. [PMID: 26944912 PMCID: PMC4948567 DOI: 10.1093/jnci/djw003] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 01/06/2016] [Indexed: 12/11/2022] Open
Abstract
Background: We analyzed the cost-effectiveness of treating incident chronic myeloid leukemia in chronic phase (CML-CP) with generic imatinib when it becomes available in United States in 2016. In the year following generic entry, imatinib’s price is expected to drop 70% to 90%. We hypothesized that initiating treatment with generic imatinib in these patients and then switching to the other tyrosine-kinase inhibitors (TKIs), dasatinib or nilotinib, because of intolerance or lack of effectiveness (“imatinib-first”) would be cost-effective compared with the current standard of care: “physicians’ choice” of initiating treatment with any one of the three TKIs. Methods: We constructed Markov models to compare the five-year cost-effectiveness of imatinib-first vs physician’s choice from a US commercial payer perspective, assuming 3% annual discounting ($US 2013). The models’ clinical endpoint was five-year overall survival taken from a systematic review of clinical trial results. Per-person spending on incident CML-CP treatment overall care components was estimated using Truven’s MarketScan claims data. The main outcome of the models was cost per quality-adjusted life-year (QALY). We interpreted outcomes based on a willingness-to-pay threshold of $100 000/QALY. A panel of European LeukemiaNet experts oversaw the study’s conduct. Results: Both strategies met the threshold. Imatinib-first ($277 401, 3.87 QALYs) offered patients a 0.10 decrement in QALYs at a savings of $88 343 over five years to payers compared with physician’s choice ($365 744, 3.97 QALYs). The imatinib-first incremental cost-effectiveness ratio was approximately $883 730/QALY. The results were robust to multiple sensitivity analyses. Conclusion: When imatinib loses patent protection and its price declines, its use will be the cost-effective initial treatment strategy for CML-CP.
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Affiliation(s)
- William V Padula
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Richard A Larson
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Stacie B Dusetzina
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Jane F Apperley
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Rudiger Hehlmann
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Michele Baccarani
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Ekkehard Eigendorff
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Joelle Guilhot
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Francois Guilhot
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Rudiger Hehlmann
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Francois-Xavier Mahon
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Giovanni Martinelli
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Jiri Mayer
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Martin C Müller
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Dietger Niederwieser
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Susanne Saussele
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Charles A Schiffer
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Richard T Silver
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Bengt Simonsson
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
| | - Rena M Conti
- Affiliations of authors:Department of Health Policy and Management, Johns Hopkins University , Baltimore, MD (WVP); Department of Medicine (RAL) and Departments of Pediatrics and of Public Health Sciences (RMC), University of Chicago, Chicago, IL; Eshelman School of Pharmacy and Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center , and Cecil G. Sheps Center for Health Services Research, University of North Carolina , Chapel Hill, NC (SBD); Department of Haematology, Hammersmith Hospital, Imperial College , London , UK (JFA); Department of Medicine (RH, SS) and Department of Hematology and Oncology (MCM), University of Heidelberg, Mannheim, Germany; Department of Haematology and Oncology, S. Orsola-Malpighi University Hospital (MB), and Department of Hematology, "L. e A. Seragnoli" (GM), University of Bologna , Bologna , Italy ; Department of Haematology and Oncology, University Hospital , Jena , Germany (EE); INSERM Centre d'Investigation Clinique (CIC) 1402, CHU de Poitiers, Poitiers, France (JG, FG); Laboratoire d'Hematologie, Universite Victor Segalen, Bordeaux, Pessac, France (FXM); Department of Internal Medicine, Hematology and Oncology, University Hospital Brno , Brno , Czech Republic (JM); Department of Hematology and Oncology, University Hospital Leipzig , Leipzig , Germany (DN); Barbara Ann Karmanos Cancer Institute, Wayne State University , Detroit, MI (CAS); Department of Medicine, Weill Cornell Medical Center , New York, NY (RTS); Uppsala University , Uppsala , Sweden (BS)
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