1
|
Dominy KM, Claudiani S, O'Hare M, Szydlo R, Gerrard G, Foskett P, Foroni L, Milojkovic D, Apperley JF, Khorashad J. Assessment of quantitative polymerase chain reaction for BCR-ABL1 transcripts in chronic myeloid leukaemia: Are improved outcomes in patients with e14a2 transcripts an artefact of technology? Br J Haematol 2022; 197:52-62. [PMID: 34997766 DOI: 10.1111/bjh.18026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/16/2021] [Indexed: 12/27/2022]
Abstract
The clinical outcome of chronic myeloid leukaemia patients has vastly improved since the introduction of tyrosine kinase inhibitor treatment, with a significant proportion of patients able to achieve treatment-free remission. However, studies have shown that patients with the e13a2 transcript were less likely to achieve major molecular response compared to those with e14a2 transcripts. Most quantitative polymerase chain reaction (PCR) assays for detection of the BCR-ABL1 fusion gene do not differentiate between the two transcripts and we therefore hypothesised that technical bias linked to the qPCR assay could partially explain the discrepancy in outcomes. We designed an e14a2-specific assay and identified no difference in results compared to an e13a2 standard assay. We then demonstrated that the commercial e14a2 standards were causing a significant overestimation of the e13a2 transcripts. Finally, we reviewed patient management after the qPCR values were corrected, using our new evaluation. We concluded that despite statistically significant differences in qPCR results, there was no impact on patient management or outcome. We conclude that, at least in our institution, it would be inappropriate to perform separate assays for patients with e13a2 or e14a2.
Collapse
Affiliation(s)
- Katherine M Dominy
- Imperial Molecular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Simone Claudiani
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Matthew O'Hare
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Richard Szydlo
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Gareth Gerrard
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK.,South East Genomic Laboratory Hub, Guy's & St Thomas' NHS Trust, London, UK
| | - Pierre Foskett
- Imperial Molecular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Letizia Foroni
- Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Dragana Milojkovic
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Jane F Apperley
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Jamshid Khorashad
- Imperial Molecular Pathology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
2
|
Eiring AM, Page BDG, Kraft IL, Mason CC, Vellore NA, Resetca D, Zabriskie MS, Zhang TY, Khorashad JS, Engar AJ, Reynolds KR, Anderson DJ, Senina A, Pomicter AD, Arpin CC, Ahmad S, Heaton WL, Tantravahi SK, Todic A, Moriggl R, Wilson DJ, Baron R, O'Hare T, Gunning PT, Deininger MW. Combined STAT3 and BCR-ABL1 inhibition induces synthetic lethality in therapy-resistant chronic myeloid leukemia. Leukemia 2014; 29:586-597. [PMID: 25134459 PMCID: PMC4334758 DOI: 10.1038/leu.2014.245] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 12/22/2022]
Abstract
Mutations in the BCR-ABL1 kinase domain are an established mechanism of tyrosine kinase inhibitor (TKI) resistance in Philadelphia chromosome-positive leukemia, but fail to explain many cases of clinical TKI failure. In contrast, it is largely unknown why some patients fail TKI therapy despite continued suppression of BCR-ABL1 kinase activity, a situation termed BCRABL1 kinase-independent TKI resistance. Here, we identified activation of signal transducer and activator of transcription 3 (STAT3) by extrinsic or intrinsic mechanisms as an essential feature of BCR-ABL1 kinase-independent TKI resistance. By combining synthetic chemistry, in vitro reporter assays, and molecular dynamics-guided rational inhibitor design and high-throughput screening, we discovered BP-5-087, a potent and selective STAT3 SH2 domain inhibitor that reduces STAT3 phosphorylation and nuclear transactivation. Computational simulations, fluorescence polarization assays, and hydrogen-deuterium exchange assays establish direct engagement of STAT3 by BP-5-087 and provide a high-resolution view of the STAT3 SH2 domain/BP-5-087 interface. In primary cells from CML patients with BCR-ABL1 kinase-independent TKI resistance, BP-5-087 (1.0 μM) restored TKI sensitivity to therapy-resistant CML progenitor cells, including leukemic stem cells (LSCs). Our findings implicate STAT3 as a critical signaling node in BCR-ABL1 kinase-independent TKI resistance, and suggest that BP-5-087 has clinical utility for treating malignancies characterized by STAT3 activation.
Collapse
Affiliation(s)
- Anna M Eiring
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Brent D G Page
- Department of Chemical and Physical Sciences, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Ira L Kraft
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Clinton C Mason
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Nadeem A Vellore
- Department of Medicinal Chemistry, College of Pharmacy, The University of Utah, Salt Lake City, Utah, USA
| | - Diana Resetca
- York University Chemistry Department, Toronto, Ontario, Canada
| | - Matthew S Zabriskie
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Tian Y Zhang
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Jamshid S Khorashad
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Alexander J Engar
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Kimberly R Reynolds
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - David J Anderson
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Anna Senina
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Anthony D Pomicter
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | - Carolynn C Arpin
- Department of Chemical and Physical Sciences, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Shazia Ahmad
- Department of Medicinal Chemistry, College of Pharmacy, The University of Utah, Salt Lake City, Utah, USA
| | - William L Heaton
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA
| | | | - Aleksandra Todic
- Department of Chemical and Physical Sciences, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Richard Moriggl
- Ludwig Boltzmann Institute for Cancer Research, Vienna, Austria
| | - Derek J Wilson
- York University Chemistry Department, Toronto, Ontario, Canada.,Center for Research in Mass Spectrometry, Department of Chemistry, York University, Toronto, Ontario, Canada
| | - Riccardo Baron
- Department of Medicinal Chemistry, College of Pharmacy, The University of Utah, Salt Lake City, Utah, USA
| | - Thomas O'Hare
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA.,Division of Hematology and Hematologic Malignancies, The University of Utah, Salt Lake City, Utah, USA
| | - Patrick T Gunning
- Department of Chemical and Physical Sciences, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Michael W Deininger
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah, USA.,Division of Hematology and Hematologic Malignancies, The University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
3
|
Marin D. Patient With Chronic Myeloid Leukemia in Complete Cytogenetic Response: What Does It Mean, and What Does One Do Next? J Clin Oncol 2014; 32:379-84. [DOI: 10.1200/jco.2013.52.9230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David Marin
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| |
Collapse
|
4
|
Holloway S, Lord K, Bethelmie-Bryan B, Shepard MW, Neely J, McLemore M, Reddy SK, Montero A, Jonas WS, Gladney SP, Khanwani SL, Reddy SC, Lahiry AK, Heffner LT, Winton E, Arellano M, Khoury HJ. Managing Chronic Myeloid Leukemia: A Coordinated Team Care Perspective. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 12:88-93. [DOI: 10.1016/j.clml.2011.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 10/24/2011] [Accepted: 10/27/2011] [Indexed: 11/27/2022]
|
5
|
Responses to second-line tyrosine kinase inhibitors are durable: an intention-to-treat analysis in chronic myeloid leukemia patients. Blood 2011; 119:1838-43. [PMID: 22174159 DOI: 10.1182/blood-2011-10-383000] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Second-generation tyrosine kinase inhibitors (2G-TKIs) are effective at inducing complete cytogenetic responses (CCyRs) in approximately half of chronic myeloid leukemia patients treated while still in the chronic phase and after failing imatinib. It is less clear whether these responses are durable. In the present study, we report the clinical outcome of 119 patients who received a 2G-TKI as second-line treatment while still in the chronic phase. In an intention-to-treat analysis, the 4-year probabilities of overall and event-free survival were 81.9% and 35.3%, respectively. Sixty-two patients discontinued the initial 2G-TKI because of resistance or intolerance. To further explore the durability of cytogenetic responses, irrespective of the need for a third-line TKI, we used the concept of "current CCyR-survival" (c-CCyRS). The c-CCyRS at 4 years was 54.4%. After introduction of a 2G-TKI, 77 patients had a 3-month BCR-ABL1/ABL1 transcript ratio of ≤ 10% and had significantly superior overall survival (91.3% vs 72.1%, P = .02), event-free survival (49.3% vs 13.0%, P < .001), and c-CCyRS (67.2% vs 11.2%, P = .0001) compared with the 33 patients with ratios > 10%. The 3-month molecular response was the only independent predictor for overall survival. Using an intention-to-treat analysis, we have shown that the responses to second-line therapies are durable. Patients destined to fare poorly can be identified early during therapy.
Collapse
|
6
|
Marin D, Ibrahim AR, Lucas C, Gerrard G, Wang L, Szydlo RM, Clark RE, Apperley JF, Milojkovic D, Bua M, Pavlu J, Paliompeis C, Reid A, Rezvani K, Goldman JM, Foroni L. Assessment of BCR-ABL1 transcript levels at 3 months is the only requirement for predicting outcome for patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors. J Clin Oncol 2011; 30:232-8. [PMID: 22067393 DOI: 10.1200/jco.2011.38.6565] [Citation(s) in RCA: 375] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE We studied BCR-ABL1 transcript levels in patients with chronic myeloid leukemia in chronic phase (CML-CP) at 3, 6, and 12 months after starting imatinib to identify molecular milestones that would predict for overall survival (OS) and other outcomes more reliably than serial marrow cytogenetics. PATIENTS AND METHODS We analyzed 282 patients with CML-CP who received imatinib 400 mg/d as first-line therapy followed by dasatinib or nilotinib if treatment with imatinib failed. We used a receiver operating characteristic curve to identify the cutoffs in transcript levels at 3, 6, and 12 months that would best predict patient outcome. We validated our findings in an independent cohort of 95 patients treated elsewhere. RESULTS Patients with transcript levels of more than 9.84% (n = 68) at 3 months had significantly lower 8-year probabilities of OS (56.9% v 93.3%; P < .001), progression-free survival, cumulative incidence of complete cytogenetic response, and complete molecular response than those with higher transcript levels. Similarly, transcript levels of more than 1.67% (n = 87) at 6 months and more than 0.53% (n = 93) at 12 months identified high-risk patients. However, transcript levels at 3 months were the most strongly predictive for the various outcomes. When we compared OS for the groups defined molecularly at 6 and 12 months with the usual cytogenetic milestones, categorization by transcript numbers was the only independent predictor for OS (relative risk, 0.207; P < .001 and relative risk, 0.158; P < .001, respectively). CONCLUSION A single measurement of BCR-ABL1 transcripts performed at 3 months is the best way to identify patients destined to fare poorly, thereby allowing early clinical intervention.
Collapse
Affiliation(s)
- David Marin
- Department of Haematology, Imperial College London, Hammersmith Hospital, Du Cane Rd, London W12 0NN, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Translating Trial-Based Molecular Monitoring Into Clinical Practice: Importance of International Standards and Practical Considerations for Community Practitioners. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:385-95. [DOI: 10.1016/j.clml.2011.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 01/25/2011] [Indexed: 11/29/2022]
|
8
|
In search of the original leukemic clone in chronic myeloid leukemia patients in complete molecular remission after stem cell transplantation or imatinib. Blood 2010; 116:1329-35. [PMID: 20462961 DOI: 10.1182/blood-2009-11-255109] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
It is not clear if absence of BCR-ABL transcripts--complete molecular response (CMR)--is synonymous with, or required for, cure of chronic myeloid leukemia (CML). Some patients achieve CMR with imatinib (IM), but most relapse shortly after treatment discontinuation. Furthermore, most patients in long-term remission (LTR) post-stem cell transplantation (SCT) are considered functionally cured, although some remain occasionally positive for low-level BCR-ABL mRNA. Interpretation of the latter is complicated because it has been observed in healthy subjects. We designed a patient-specific, highly sensitive, DNA quantitative polymerase chain reaction to test follow-up samples for the original leukemic clone, identified by its unique genomic BCR-ABL fusion (gBCR-ABL). In 5 IM-treated patients in CMR, gBCR-ABL was detected in transcript-negative samples; 4 patients became gBCR-ABL-negative with continuing IM therapy. In contrast, of 9 patients in LTR (13-27 years) post-SCT, gBCR-ABL was detected in only 1, despite occasional transcript-positive samples in 8 of them. In conclusion, in IM-treated patients, absence of transcripts should not be interpreted as absence of the leukemic clone, although continuing IM after achievement of CMR may lead to further reduction of residual disease. Post-SCT, we found little evidence that the transcripts occasionally detected originate from the leukemic clone.
Collapse
|
9
|
Milojkovic D, Nicholson E, Apperley JF, Holyoake TL, Shepherd P, Drummond MW, Szydlo R, Bua M, Foroni L, Reid A, Khorashad JS, de Lavallade H, Rezvani K, Paliompeis C, Goldman JM, Marin D. Early prediction of success or failure of treatment with second-generation tyrosine kinase inhibitors in patients with chronic myeloid leukemia. Haematologica 2009; 95:224-31. [PMID: 19833633 DOI: 10.3324/haematol.2009.012781] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Second-generation tyrosine kinase inhibitors induce cytogenetic responses in approximately 50% of patients with chronic myeloid leukemia in chronic phase in whom imatinib treatment has failed. However, it has not yet been established which of the patients in whom imatinib treatment fails are likely to benefit from therapy with second-generation tyrosine kinase inhibitors. DESIGN AND METHODS We analyzed a cohort of 80 patients with chronic myeloid leukemia who were resistant to imatinib and who were treated with dasatinib or nilotinib while still in first chronic phase. We devised a scoring system to predict the probability of these patients achieving complete cytogenetic response when treated with second-generation tyrosine kinase inhibitors. RESULTS The system was based on three factors: cytogenetic response to imatinib, Sokal score and recurrent neutropenia during imatinib treatment. We validated the score in an independent group of 28 Scottish patients. We also studied the relationship between cytogenetic responses at 3, 6 and 12 months and subsequent outcome. We classified the 80 patients into three categories, those with good risk (n=24), intermediate risk (n=27) and poor risk (n=29) with 2.5-year cumulative incidences of complete cytogenetic response of 100%, 52.2% and 13.8%, respectively (P<0.0001). Moreover, patients who had less than 95% Philadelphia chromosome-positive metaphases at 3 months, those with 35% or less Philadelphia chromosome-positive metaphases at 6 months and patients in complete cytogenetic response at 12 months all had significantly better outcomes than patients with lesser degrees of cytogenetic response. CONCLUSIONS Factors measurable before starting treatment can accurately predict response to second-generation tyrosine kinase inhibitors. Cytogenetic responses at 3, 6 and 12 months may influence the decision to continue treatment with second-generation tyrosine kinase inhibitors.
Collapse
Affiliation(s)
- Dragana Milojkovic
- Department of Haematology, Imperial College London, Du Cane Road, London W12 0NN, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Response to Imatinib mesylate in chronic myeloid leukemia patients with variant BCR-ABL fusion transcripts. Ann Hematol 2009; 89:241-7. [DOI: 10.1007/s00277-009-0822-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
|
11
|
Béné MC, Kaeda JS. How and why minimal residual disease studies are necessary in leukemia: a review from WP10 and WP12 of the European LeukaemiaNet. Haematologica 2009; 94:1135-50. [PMID: 19586938 PMCID: PMC2719036 DOI: 10.3324/haematol.2008.004267] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Revised: 03/18/2009] [Accepted: 03/19/2009] [Indexed: 12/21/2022] Open
Abstract
Resistance to therapeutic agents is a major factor in the failure of cancer treatments. In leukemia, the resistant cells remaining in the bone marrow and/or peripheral blood constitute minimal residual disease and are detectable by highly sensitive assays when the patient appears to be in complete remission. Early detection of the expansion of residual cells permits clinical intervention with the aim of reversing the proliferation of resistant leukemic cells. Therefore, accurate and precise measurement of minimal residual disease can greatly enhance optimization of oncology patients' clinical management. This notion is supported by a large body of data among chronic myeloid leukemia patients, but minimal residual disease detection and monitoring is increasingly applied to other types of leukemia, and is starting to be a factor in decision-making for some therapeutic trials in childhood acute lymphoblastic leukemia. Here, from the solid ground of minimal residual disease detection in chronic myeloid leukemia, the current state of the art and development of molecular techniques in other leukemias and the growing field of multiparameter flow cytometry are reviewed in two separate parts reporting on the respective advances, advantages and pitfalls of these emerging methods.
Collapse
|
12
|
Abstract
AbstractFor adult patients who present with chronic myeloid leukemia (CML) in chronic phase it is now generally agreed that initial treatment should start with the tyrosine kinase inhibitor (TKI) imatinib at 400 mg daily. Five years after starting imatinib about 60% of these patients will be in complete cytogenetic response (CCyR), still taking imatinib; an appreciable proportion of these will have achieved a major molecular response, defined as a 3-log reduction in the level of BCR-ABL1 transcripts in their blood. The patients in CCyR seem to have a very low risk of relapse to chronic phase or of progression to advanced phase. Other patients may be resistant to imatinib or may experience significant side effects that require change of therapy. The best method of monitoring responding patients is to enumerate Philadelphia chromosome–positive marrow metaphases at 3-month intervals until CCyR and to perform RQ-PCR for BCR-ABL1 transcripts at 3-month intervals after starting imatinib. The recommendations for defining “failure” and “sub-optimal response” proposed by the European LeukemiaNet in 2006 have proved to be a major contribution to assessing responses in individual patients and are now being updated. Patients who fail imatinib may respond to second-generation TKIs, but allogeneic stem cell transplantation still plays an important role for eligible patients who fare badly with TKIs. Patients who present in advanced phases of CML should be treated initially with TKI alone or with TKI in conjunction with cytotoxic drugs, but their overall prognosis is likely to be much inferior to that of those presenting in early chronic phase.
Collapse
|
13
|
Mishra M, Jain D, Fauzdar A, Kandpal U, Makroo RN, Raina VP. Effectiveness of Using IVD Certified Platform for Monitoring Minimal Residual Disease in Chronic Myelogenous Leukemia Patient. APOLLO MEDICINE 2008. [DOI: 10.1016/s0976-0016(11)60160-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
|
14
|
Khorashad JS, de Lavallade H, Apperley JF, Milojkovic D, Reid AG, Bua M, Szydlo R, Olavarria E, Kaeda J, Goldman JM, Marin D. Finding of kinase domain mutations in patients with chronic phase chronic myeloid leukemia responding to imatinib may identify those at high risk of disease progression. J Clin Oncol 2008; 26:4806-13. [PMID: 18645191 PMCID: PMC10466446 DOI: 10.1200/jco.2008.16.9953] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 05/27/2008] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Kinase domain (KD) mutations in the BCR-ABL gene are associated with resistance to imatinib in chronic myeloid leukemia (CML) but their incidence and prognostic significance in chronic phase (CP) patients without resistance are unclear. PATIENTS AND METHODS We analyzed outcome for 319 patients with CML-CP who were treated with imatinib; 171 were in early CP (ECP) and 148 were in late CP (LCP). Patients were screened routinely for mutations using direct sequencing regardless of response status. The 5-year cumulative incidence of mutations was 6.6% for ECP and 17% for LCP patients. RESULTS Of the 319 patients, 214 (67%) achieved complete cytogenetic responses (CCyR). The identification of a mutation without other evidence of imatinib resistance was highly predictive for loss of CCyR (RR, 3.8; P = .005) and for progression to advanced phase (RR, 2.3; P = .01), though the intervals from first identification to loss of CCyR and disease progression were relatively long (median, 21 and 16 months, respectively). Mutations in the P-loop (excluding residue 244) were associated with a higher risk of progression than mutations elsewhere. CONCLUSION We conclude that routine mutation screening of patients who appear to be responding to imatinib may identify those at high risk of disease progression.
Collapse
Affiliation(s)
- Jamshid S. Khorashad
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Hugues de Lavallade
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Jane F. Apperley
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Dragana Milojkovic
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Alistair G. Reid
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Marco Bua
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Richard Szydlo
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Eduardo Olavarria
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - Jaspal Kaeda
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - John M. Goldman
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| | - David Marin
- From the Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, United Kingdom
| |
Collapse
|
15
|
European LeukemiaNet criteria for failure or suboptimal response reliably identify patients with CML in early chronic phase treated with imatinib whose eventual outcome is poor. Blood 2008; 112:4437-44. [PMID: 18716134 DOI: 10.1182/blood-2008-06-162388] [Citation(s) in RCA: 264] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The majority of patients with chronic myeloid leukemia in chronic phase gain substantial benefit from imatinib but some fail to respond or lose their initial response. In 2006, the European LeukemiaNet published recommendations designed to help identify patients responding poorly to imatinib. Patients were evaluated at 3, 6, 12, and 18 months and some were classified as "failure" or "suboptimal responders." We analyzed outcomes for 224 patients with chronic myeloid leukemia in chronic phase treated in a single institution to validate these recommendations. Patients were followed for a median of 46.1 months. At each time point, patients classified as "failure" showed significantly worse survival, progression-free survival, and cytogenetic response than other patients; for example, based on the assessment at 12 months, the 5-year survival was 87.1% versus 95.1% (P = .02), progression-free survival 76.% versus 90% (P = .002), and complete cytogenetic response rate 26.7% versus 94.1% (P < .001). Similarly, the criteria for "suboptimal response" at 6 and 12 months identified patients destined to fare badly, although criteria at 18 months were less useful. The predictive value of some other individual criteria varied. In general, the LeukemiaNet criteria have useful predictive value, but a case could now be made for combining the categories "failure" and "suboptimal response."
Collapse
|
16
|
de Lavallade H, Apperley JF, Khorashad JS, Milojkovic D, Reid AG, Bua M, Szydlo R, Olavarria E, Kaeda J, Goldman JM, Marin D. Imatinib for newly diagnosed patients with chronic myeloid leukemia: incidence of sustained responses in an intention-to-treat analysis. J Clin Oncol 2008; 26:3358-63. [PMID: 18519952 DOI: 10.1200/jco.2007.15.8154] [Citation(s) in RCA: 421] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Imatinib is remarkably effective in treating newly diagnosed patients with chronic myeloid leukemia (CML) in chronic phase (CP). To date, most of the available data come from a single multicenter study in which some of the patients were censored for diverse reasons. Here, we report our experience in treating patients at a single institution in a setting where all events were recorded. PATIENTS AND METHODS A total of 204 consecutive adult patients with newly diagnosed CML in CP received imatinib from June 2000 until August 2006. Response (hematologic, cytogenetic, and molecular), progression-free survival (PFS) and survival were evaluated. RESULTS At 5 years, cumulative incidences of complete cytogenetic response (CCyR) and major molecular response (MMR) were 82.7% and 50.1%, respectively. Estimated overall survival and PFS were 83.2% and 82.7%, respectively. By 5 years, 25% of patients had discontinued imatinib treatment because of an unsatisfactory response and/or toxicity. The 5-year probability of remaining in major cytogenetic response while still receiving imatinib was 62.7%. Patients achieving a CCyR at 1 year had a better PFS and overall survival than those failing to reach CCyR, but achieving a MMR conferred no further advantage. The identification of a kinase domain mutation was the only factor predicting for loss of CCyR. CONCLUSION Imatinib is highly effective in most patients with CML-CP; patients who respond are likely to live substantially longer than those treated with earlier therapies. Achieving CCyR correlated with PFS and overall survival, but achieving MMR had no further predictive value. However, approximately one third of patients still need better therapy.
Collapse
Affiliation(s)
- Hugues de Lavallade
- Department of Haematology, Imperial College London, Du Cane Rd, London W12 0NN, United Kingdom
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
Tyrosine kinase inhibitor (TKI) therapy for chronic myeloid leukaemia (CML) is the consummate success story for targeted therapy, yet relapse is a nearly inevitable consequence of cessation or interruption of therapy. Primitive TKI-refractory CML stem cells are the likely source of these relapses, as they provide sanctuary for the Philadelphia chromosome. In advanced disease, their progressively anaplastic progeny ultimately maintain CML independently of the CML haematopoietic stem cell (HSC). Interestingly, there are at least two distinct cell types capable of self-renewal in different phases of CML: first, a primitive HSC with BCR-ABL mutation, which maintains the more indolent chronic-phase disease and, second, a coexisting mutated progenitor cell which acquires stem cell characteristics responsible for rapid cell expansion in advanced disease.
Collapse
MESH Headings
- Benzamides
- Drug Resistance, Neoplasm/genetics
- Epigenesis, Genetic
- Fusion Proteins, bcr-abl/genetics
- Hematopoietic Stem Cells/enzymology
- Hematopoietic Stem Cells/pathology
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Neoplastic Stem Cells/enzymology
- Neoplastic Stem Cells/pathology
- Piperazines/therapeutic use
- Protein Kinase Inhibitors/therapeutic use
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Pyrimidines/therapeutic use
- Tumor Suppressor Proteins/genetics
Collapse
Affiliation(s)
- Michael Savona
- University of Michigan, Internal Medicine-Hematology Oncology, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-45936, USA.
| | | |
Collapse
|
18
|
Quantitative detection of bcr-abl transcripts in chronic myeloid leukemia. ACTA ACUST UNITED AC 2008; 57:388-91. [PMID: 18387753 DOI: 10.1016/j.patbio.2007.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 12/14/2007] [Indexed: 11/23/2022]
Abstract
The optimal management of malignant haematological disorders depend on the degree of tumor load reduction after therapy. Chronic myeloid leukemia constitutes a clinical model for molecular detection and therapy surveillance of malignant disease since this entity was the first leukemia shown to be associated with a specific bcr-abl fusion gene in the patient's leukemia cells. Molecular monitoring of bcr-abl transcript levels by real-time quantitative PCR is increasingly used to assess treatment response in patients with chronic myeloid leukemia (CML). This has become particularly relevant in the era of imatinib therapy when residual levels of leukaemia usually fall below the level of detection by bone marrow cytogenetic analysis. We monitored bcr-abl transcript levels by quantitative real time PCR in 50 tunisian patients treated with imatinib for chronic myeloid leukemia in chronic phase for a median of 29 months (3-60) after they started imatinib.
Collapse
|
19
|
Monitoring minimal residual disease in patients with chronic myeloid leukemia after treatment with tyrosine kinase inhibitors. Curr Opin Hematol 2008; 15:134-9. [DOI: 10.1097/moh.0b013e3282f42898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
20
|
Abstract
Although it is now generally accepted that imatinib is the best initial treatment for patients newly diagnosed with chronic myeloid leukemia (CML) in chronic phase, a number of questions remain unanswered. For example, (1) Is imatinib the best initial treatment for every chronic-phase patient? (2) At what dose should imatinib be started? (3) How should response to treatment be monitored? (4) For how long should the drug be continued in patients who have achieved and maintain a complete molecular response? (5) How does one handle a patient who achieves a 2-log but not a 3-log reduction in BCR-ABL transcripts? (6) How should response or failure be defined? (7) For the patient deemed to have failed imatinib, should one offer dasatinib or nilotinib? (8) For the patient who has failed imatinib but has a possible allogeneic transplant donor, should one offer dasatinib or nilotinib before recommending a transplantation? (9) Should the transplantation be myeloablative or reduced intensity conditioning? (10) How should one treat the patient who relapses after allografting? This paper will address these issues, many of which cannot yet be answered definitively.
Collapse
Affiliation(s)
- John M Goldman
- Department of Haematology, Imperial College at Hammersmith Hospital, London, United Kingdom.
| |
Collapse
|
21
|
Jółkowska J, Derwich K, Dawidowska M. Methods of minimal residual disease (MRD) detection in childhood haematological malignancies. J Appl Genet 2007; 48:77-83. [PMID: 17272865 DOI: 10.1007/bf03194661] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The appropriate management of haematological disorders must rely on a precise and long-term monitoring of the patient's response to chemotherapy and radiotherapy. Clinical data are not sufficient and that is why in the last decade it became the most important to improve the knowledge of haematological diseases on the basis of molecular techniques and molecular markers. The presence of residual malignant cells among normal cells is termed minimal residual disease (MRD). Nowadays a great progress has been made in the treatment of malignant diseases and in the development of reliable molecular techniques, which are characterised by high sensitivity (10-3- 10-6) and ability to distinguish between normal and malignant cells at diagnosis and during follow-up. Especially, MRD data based on quantitative analysis (RQ-PCR, RT-RQ-PCR) appear to be crucial for appropriate evaluation of treatment response in many haematological malignancies. Implementation of standardized approaches for MRD assessment into routine molecular diagnostics available in all oncohaematological centres should be regarded nowadays a crucial point in further MRD study development.
Collapse
Affiliation(s)
- Justyna Jółkowska
- Department of Molecular and Clinical Genetics, Institute of Human Genetics, Polish Academy of Sciences, Poznań, Poland.
| | | | | |
Collapse
|
22
|
Gullo CA, Chuah CTH, Hwang WYK, Teoh GKH. Detection and Quantification of the Abelson Tyrosine Kinase Domains of the bcr-abl Gene Translocation in Chronic Myeloid Leukaemia Using Genomic Quantitative Real-time Polymerase Chain Reaction. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2006. [DOI: 10.47102/annals-acadmedsg.v35n10p680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Introduction: Since undetectable BCR-ABL mRNA transcription does not always indicate eradication of the Ph+ CML clone and since transcriptionally silent Ph+ CML cells exist, quantitation by genomic PCR of bcr-abl genes can be clinically useful. Furthermore, hotspot mutations in the Abelson tyrosine kinase (ABLK) domain of the bcr-abl gene translocation in Philadelphia chromosome-positive (Ph+) chronic myeloid leukaemia (CML) cells confer resistance on the specific kinase blocking agent, STI571.
Materials and Methods: Genomic DNA from K562, CESS and patient CML cells were amplified using rapid cycle quantitative real-time polymerase chain reaction for the gene regions spanning the mutation hotspots. In assays for ABLK exons 4 or 6, exonic or intronic PCR primers were used.
Results: We show that separation of cycle threshold (CT) values for log-fold amplicon quantification was 2.9 cycles for ABLK exon 4, and 3.8 cycles for exon 6 with rapid amplification times. K562 CML cells were found to have a ~2 log-fold ABLK gene amplification. In contrast, patient CML cells had CT differences of 2.2 for both exon, suggesting that there was no significant ABLK gene amplification. DNA sequencing confirmed that neither K562 nor patient CML cells contained ABLK hotspot mutations. Messenger RNA transcription analysis permitted the assessment of BCR-ABL transcription, which was qualitatively correlated to genomic amplification.
Conclusions: This novel Q-PCR assay was found to have high fidelity and legitimacy, and potentially useful for monitoring minimal residual disease, transcriptionally silent Ph+ CML cells, and bcr-abl gene amplification.
Key words: Drug resistance, Haematologic neoplasms, Molecular diagnostic techniques, Philadelphia chromosome
Collapse
|
23
|
Khorashad JS, Anand M, Marin D, Saunders S, Al-Jabary T, Iqbal A, Margerison S, Melo JV, Goldman JM, Apperley JF, Kaeda J. The presence of a BCR-ABL mutant allele in CML does not always explain clinical resistance to imatinib. Leukemia 2006; 20:658-63. [PMID: 16467863 DOI: 10.1038/sj.leu.2404137] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The expansion of a leukemia clone bearing a Bcr-Abl kinase domain mutation is associated with acquired resistance to imatinib and may also predict disease progression in patients with Philadelphia-positive chronic myeloid leukemia (CML). Here we report results of pyrosequencing to quantitate the non-mutated and mutant alleles in 12 CML patients monitored over periods ranging from 11 to 58 months, and describe three contrasting kinetic patterns: Group 1 - in four patients total BCR-ABL transcript numbers remained high with the mutant allele predominating; Group 2 - in four patients the total number of BCR-ABL transcripts fell to low levels but the mutant allele predominated; and Group 3 - in four other patients the total level of transcripts remained high (n = 2) or fell (n = 2) but the mutant clone persisted at relatively low level. In Group 2 the mutant leukemia clone was presumably still relatively sensitive to imatinib but in Group 1 the leukemia could be classified as resistant. In Group 3 patients the imatinib sensitivity of the leukemia was variable. We conclude that a mutant clone does not necessarily have a proliferative advantage and its presence does not always account for resistance to imatinib. Other mechanisms underlie resistance in at least some patients.
Collapse
MESH Headings
- Adult
- Aged
- Alleles
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Benzamides
- Drug Resistance, Neoplasm/genetics
- Female
- Fusion Proteins, bcr-abl/drug effects
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- Kinetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Mutation
- Piperazines/pharmacology
- Piperazines/therapeutic use
- Protein-Tyrosine Kinases/genetics
- Pyrimidines/pharmacology
- Pyrimidines/therapeutic use
- Sensitivity and Specificity
- Sequence Analysis, DNA
- Transcription, Genetic/genetics
Collapse
Affiliation(s)
- J S Khorashad
- Department of Haematology, Hammersmith Hospitals Trust, Imperial College London, London, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Hughes T, Deininger M, Hochhaus A, Branford S, Radich J, Kaeda J, Baccarani M, Cortes J, Cross NCP, Druker BJ, Gabert J, Grimwade D, Hehlmann R, Kamel-Reid S, Lipton JH, Longtine J, Martinelli G, Saglio G, Soverini S, Stock W, Goldman JM. Monitoring CML patients responding to treatment with tyrosine kinase inhibitors: review and recommendations for harmonizing current methodology for detecting BCR-ABL transcripts and kinase domain mutations and for expressing results. Blood 2006; 108:28-37. [PMID: 16522812 PMCID: PMC1895821 DOI: 10.1182/blood-2006-01-0092] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 02/18/2006] [Indexed: 01/14/2023] Open
Abstract
The introduction in 1998 of imatinib mesylate (IM) revolutionized management of patients with chronic myeloid leukemia (CML) and the second generation of tyrosine kinase inhibitors may prove superior to IM. Real-time quantitative polymerase chain reaction (RQ-PCR) provides an accurate measure of the total leukemiacell mass and the degree to which BCR-ABL transcripts are reduced by therapy correlates with progression-free survival. Because a rising level of BCR-ABL is an early indication of loss of response and thus the need to reassess therapeutic strategy, regular molecular monitoring of individual patients is clearly desirable. Here we summarize the results of a consensus meeting that took place at the National Institutes of Health (NIH) in Bethesda in October 2005. We make suggestions for (1) harmonizing the differing methodologies for measuring BCR-ABL transcripts in patients with CML undergoing treatment and using a conversion factor whereby individual laboratories can express BCR-ABL transcript levels on an internationally agreed scale; (2) using serial RQ-PCR results rather than bone marrow cytogenetics or fluorescence in situ hybridization (FISH) for the BCR-ABL gene to monitor individual patients responding to treatment; and (3) detecting and reporting Philadelphia (Ph) chromosome-positive subpopulations bearing BCR-ABL kinase domain mutations. We recognize that our recommendations are provisional and will require revision as new evidence emerges.
Collapse
MESH Headings
- Drug Monitoring/methods
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Mutation
- Protein Kinase Inhibitors/therapeutic use
- Protein Structure, Tertiary/genetics
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Protein-Tyrosine Kinases/genetics
- Reverse Transcriptase Polymerase Chain Reaction/methods
- Reverse Transcriptase Polymerase Chain Reaction/standards
- Sensitivity and Specificity
Collapse
Affiliation(s)
- Timothy Hughes
- Institute of Medical and Veterinary Science, Adelaide, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Goldman J, Gordon M. Why do chronic myelogenous leukemia stem cells survive allogeneic stem cell transplantation or imatinib: does it really matter? Leuk Lymphoma 2006; 47:1-7. [PMID: 16321820 DOI: 10.1080/10428190500407996] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
It is generally accepted that allogeneic stem cell transplantation can 'cure' chronic myelogenous leukemia (CML), although occasional patients relapse more than 10 years after the transplant procedure. Such cures presumably result from the combined effects of leukemia stem cells (LSCs) of the conditioning regimen and the graft-vs.-leukemia (GvL) effect mediated by donor-derived T lymphocytes. The advent of imatinib has revolutionized the management of patients with CML, but much evidence suggests that it does not eradicate all LSCs, which theoretically remain a potential source of relapse to chronic phase or advanced phase disease. Moreover, sub-clones of Philadelphia-positive cells bearing mutations that code for amino-acid substitutions in the Bcr-Abl kinase domain can be identified in patients receiving treatment with imatinib and are associated with varying degrees of resistance to this agent. In the present review, we postulate that LSCs, similar to their normal counterparts, may alternate between cycling and quiescent modes. In the cycling mode, they may express Bcr-Abl protein and be susceptible to the acquisition of additional mutations, whereas, in the quiescent mode, they may express little or no Bcr-Abl oncoprotein, cannot acquire additional mutations and are unaffected by imatinib. Thus, a patient who starts treatment early in the natural history of CML, and who responds to imatinib clinically, may not have had the opportunity to acquire additional mutations in LSCs. In this case, the persistence long-term of quiescent 'non-mutated' LSCs despite imatinib treatment might be consistent with freedom from relapse to chronic or advanced phase disease, provided that they remain vulnerable to imatinib when they are recruited into cycle. Conversely, when imatinib resistant Philadelphia-positive sub-clones predominate, this is likely to be due to the recruitment to hematopoiesis of quiescent stem cells that had been in cycle before administration of imatinib and that had acquired additional mutations; in such cases, the best approach to eradication of residual LSCs might be to target expressed proteins thought to be targets for the GvL effect.
Collapse
MESH Headings
- Benzamides
- Cell Survival/drug effects
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Models, Biological
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/immunology
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Stem Cell Transplantation
- Transplantation, Homologous
Collapse
Affiliation(s)
- John Goldman
- Hematology Branch, National Heart, Lung and Blood Institute, NIH, Bethesda, MD 20892-1202, USA.
| | | |
Collapse
|
26
|
Kaeda J, O'Shea D, Szydlo RM, Olavarria E, Dazzi F, Marin D, Saunders S, Khorashad JS, Cross NCP, Goldman JM, Apperley JF. Serial measurement of BCR-ABL transcripts in the peripheral blood after allogeneic stem cell transplantation for chronic myeloid leukemia: an attempt to define patients who may not require further therapy. Blood 2006; 107:4171-6. [PMID: 16449534 PMCID: PMC1895293 DOI: 10.1182/blood-2005-08-3320] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We identified 243 patients with Philadelphia (Ph) chromosome-positive chronic myeloid leukemia (CML) who had BCR-ABL transcripts monitored by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) after allogeneic stem cell transplantation for a median of 84.3 months. Individual patients were regarded as having achieved molecular relapse (MR) if the BCR-ABL/ABL ratio exceeded 0.02% on 3 occasions or reached 0.05% on 2 occasions. Patients were allocated to 1 of 4 categories: (1) 36 patients were "persistently negative" or had a single low-level positive result; (2) 51 patients, "fluctuating positive, low level," had more than 1 positive result but never more than 2 consecutive positive results; (3) 27 patients, "persistently positive, low level," had persisting low levels of BCR-ABL transcripts but never more than 3 consecutive positive results; and (4) 129 patients relapsed. In 107 of these, relapse was based initially only on molecular criteria; in 72 (67.3%) patients the leukemia progressed to cytogenetic or hematologic relapse either prior to or during treatment with donor lymphocyte infusions. We conclude that the pattern of BCR-ABL transcript levels after allograft is variable; only a minority of patients with fluctuating or persistent low levels of BCR-ABL transcripts satisfied our definitions of MR, whereas the majority of patients who did so were likely to progress further.
Collapse
MESH Headings
- Adult
- Biomarkers/blood
- Disease Progression
- Female
- Fusion Proteins, bcr-abl/blood
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/blood
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Male
- Stem Cell Transplantation
- Survivors
- Transcription, Genetic
- Transplantation, Homologous/physiology
- Treatment Outcome
Collapse
Affiliation(s)
- Jaspal Kaeda
- Department of Haematology, Imperial College at Hammersmith Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Barnes DJ, Palaiologou D, Panousopoulou E, Schultheis B, Yong ASM, Wong A, Pattacini L, Goldman JM, Melo JV. Bcr-Abl expression levels determine the rate of development of resistance to imatinib mesylate in chronic myeloid leukemia. Cancer Res 2005; 65:8912-9. [PMID: 16204063 DOI: 10.1158/0008-5472.can-05-0076] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic myeloid leukemia (CML) starts with the acquisition of a BCR-ABL fusion gene in a single hematopoietic stem cell, but the time to progression is unpredictable. Although the tyrosine kinase inhibitor imatinib mesylate is highly effective in the treatment of CML, its continuous administration is associated with development of resistance, particularly in advanced phase or blast crisis. We investigate here whether a feature of disease progression (i.e., elevated expression of Bcr-Abl in CD34+ progenitor cells from CML patients in blast crisis) has any bearing on the kinetics of resistance to imatinib. By studying cell lines that exogenously express Bcr-Abl over the range found from chronic phase to blast crisis of CML, we show that cells expressing high amounts of Bcr-Abl, as in blast crisis, are much less sensitive to imatinib and, more significantly, take a substantially shorter time for yielding a mutant subclone resistant to the inhibitor than cells with low expression levels, as in chronic phase. Our data suggest that the differential levels of the Bcr-Abl oncoprotein expressed by CD34+ CML cells may reflect the extent and duration of their response to imatinib; the relatively high levels of oncoprotein in advanced-phase disease may underlie the observed rapid development of resistance.
Collapse
MESH Headings
- Adaptor Proteins, Signal Transducing/metabolism
- Antineoplastic Agents/pharmacology
- Benzamides
- Blast Crisis/genetics
- Blast Crisis/metabolism
- Cell Line, Tumor
- Drug Resistance, Neoplasm
- Fusion Proteins, bcr-abl/biosynthesis
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Nuclear Proteins/metabolism
- Phosphorylation
- Piperazines/pharmacology
- Protein Structure, Tertiary
- Proto-Oncogene Proteins c-abl/biosynthesis
- Proto-Oncogene Proteins c-abl/genetics
- Proto-Oncogene Proteins c-abl/metabolism
- Pyrimidines/pharmacology
- STAT5 Transcription Factor/metabolism
- Stem Cells/metabolism
- Stem Cells/pathology
Collapse
Affiliation(s)
- David J Barnes
- Department of Haematology, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Fugazza G, Garuti A, Marchelli S, Miglino M, Bruzzone R, Gatti AM, Castello S, Sessarego M. Masked Philadelphia chromosome due to atypical BCR/ABL localization on the 9q34 band and duplication of the der(9) in a case of chronic myelogenous leukemia. ACTA ACUST UNITED AC 2005; 163:173-5. [PMID: 16337863 DOI: 10.1016/j.cancergencyto.2005.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 05/10/2005] [Accepted: 05/17/2005] [Indexed: 11/23/2022]
Abstract
The cytogenetic studies and molecular evaluation of a Philadelphia chromosome negative chronic myelogenous leukemia patient with trisomy 21 (100% metaphases) and trisomy 9 (50% metaphases) at diagnosis are described. Fluorescence in situ hybridization revealed an atypical location of the BCR/ABL fusion signal on 9q, which was duplicated in cells with trisomy 9 simulating a double Ph. The patient was successfully treated with Glivec (also known as Gleevec; Novartis, Basel, Switzerland) and achieved complete hematological and cytogenetic response as well as a reduction of BCR/ABL transcripts detected by real-time quantitative PCR.
Collapse
MESH Headings
- Chromosomes, Human, Pair 9
- Gene Duplication
- Genes, abl
- Humans
- In Situ Hybridization, Fluorescence
- Karyotyping
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/genetics
- Male
- Middle Aged
- Philadelphia Chromosome
- Polymerase Chain Reaction
- Trisomy
Collapse
Affiliation(s)
- Giuseppina Fugazza
- Dipartimento di Medicina Interna e Dipartimento di Ematologia e Oncologia, Università degli Studi di Genova, Viale Benedetto XV/6, 16132 Genova, Italy
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Marin D, Kaeda J, Szydlo R, Saunders S, Fleming A, Howard J, Andreasson C, Bua M, Olavarria E, Rahemtulla A, Dazzi F, Kanfer E, Goldman JM, Apperley JF. Monitoring patients in complete cytogenetic remission after treatment of CML in chronic phase with imatinib: patterns of residual leukaemia and prognostic factors for cytogenetic relapse. Leukemia 2005; 19:507-12. [PMID: 15703781 DOI: 10.1038/sj.leu.2403664] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We monitored BCR-ABL transcript levels by quantitative real-time PCR in 103 patients treated with imatinib for chronic myeloid leukaemia in chronic phase for a median of 30.3 months (range 5.5-49.9) after they achieved complete cytogenetic remission (CCyR). The patients could be divided into three groups: (1) in 32 patients transcript levels continued to decline during the period of observation (nadir BCR-ABL/ABL ratio 0.015%); in five of these patients BCR-ABL transcripts became undetectable on repeated testing, (2) in 42 patients the transcript levels reached a plateau and (3) in 26 patients transcript numbers increased and the initial CCyR was lost. Three patients were not evaluable. Patients who remained in CCyR for at least 24 months appeared to have a low risk of subsequent cytogenetic relapse. We conclude that the pattern of 'residual' disease after achieving CCyR on imatinib is variable: some patients in CCyR show a progressive reduction in the level of residual disease, some reach a plateau where transcript numbers are relatively stable and others relapse with Ph-positive metaphases.
Collapse
MESH Headings
- Adolescent
- Adult
- Aged
- Antineoplastic Agents/therapeutic use
- Benzamides
- Female
- Follow-Up Studies
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- Incidence
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/epidemiology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Neoplasm, Residual/drug therapy
- Neoplasm, Residual/epidemiology
- Neoplasm, Residual/genetics
- Piperazines/therapeutic use
- Polymerase Chain Reaction
- Prognosis
- Pyrimidines/therapeutic use
- Recurrence
- Remission Induction
- Risk Factors
Collapse
Affiliation(s)
- D Marin
- Department of Haematology, Imperial College London at Hammersmith Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Goldman J. Monitoring minimal residual disease in BCR-ABL-positive chronic myeloid leukemia in the imatinib era. Curr Opin Hematol 2005; 12:33-9. [PMID: 15604889 DOI: 10.1097/01.moh.0000148551.93303.9e] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The total number of leukemia cells in the body is reduced very substantially in patients with BCR-ABL-positive chronic myeloid leukemia (CML) responding to imatinib. This reduction is seen first as restoration of Ph negativity in blood and marrow and thereafter as decreasing BCR-ABL transcript levels assayed by quantitative polymerase chain reaction (PCR). Most patients with newly diagnosed chronic-phase CML who receive imatinib achieve complete cytogenetic remission (CCYR) and low levels of BCR-ABL transcripts, a status that seems to predict for relatively long survival compared with previous treatments. RECENT FINDINGS Patients treated with 400 mg daily who achieved a reduction in BCR-ABL transcript numbers equal or greater than 3 logs compared with a baseline value have a significantly better progression-free survival than those who achieved lesser degrees of response. The presence of Ph-positive subclones with point mutations in the ABL kinase domain correlates with "acquired" resistance to imatinib and some mutations are associated with greater resistance than others. Preliminary evidence suggests that P-loop mutations are especially likely to be associated with progression to advanced-phase disease. SUMMARY Patients with CML should be monitored routinely by serial cytogenetic analysis of bone marrow until Ph negativity is achieved. Thereafter serial quantitative-PCR studies should be undertaken at approximately 3-month intervals and probably also bone marrow cytogenetic studies at longer intervals. Routine studies for ABL kinase domain mutations may also be advisable. The observation of increasing quantities of residual leukemia or expansion of a mutated clone suggests the need to modify therapy.
Collapse
MESH Headings
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Benzamides
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Mutation
- Neoplasm, Residual/diagnosis
- Piperazines/pharmacology
- Piperazines/therapeutic use
- Protein Structure, Tertiary
- Protein-Tyrosine Kinases/chemistry
- Pyrimidines/pharmacology
- Pyrimidines/therapeutic use
- Sensitivity and Specificity
- WT1 Proteins/analysis
- WT1 Proteins/biosynthesis
Collapse
Affiliation(s)
- John Goldman
- Imperial College London at Hammersmith Hospital, London, UK.
| |
Collapse
|
31
|
Faderl S, Hochhaus A, Hughes T. Monitoring of minimal residual disease in chronic myeloid leukemia. Hematol Oncol Clin North Am 2004; 18:657-70, ix-x. [PMID: 15271398 DOI: 10.1016/j.hoc.2004.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Detection and monitoring of minimal residual disease has become one of the most prevalent topics in chronic myeloid leukemia(CML) therapy. The goal of early detection of residual disease is to allow timely therapeutic intervention before overt relapse of therapy resistant disease occurs. The most powerful tool to serve this purpose is polymerase chain reaction (PCR). Major improvements in assay techniques have advanced PCR from a purely qualitative test with considerable variability of test results to a real-time quantitative assay with far more reproducible results than were possible before. At the same time, treatment of CML has changed dramatically since the introduction of imatinib. Integration of therapy and molecular assays such as PCR, in addition to a profound understanding of the pathophysiology of CML, has assumed even more importance. Quantitative PCR testing has become the standard monitoring strategy for patients undergoing stem cell transplantation. Although correlations have been established between positive test results and probability of relapse, no absolute guidelines for monitoring exist, especially for patients treated with imatinib.
Collapse
Affiliation(s)
- Stefan Faderl
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Box 428, 1515 Holcombe Bouelvard, Houston, TX 77030, USA.
| | | | | |
Collapse
|
32
|
Raanani P, Ben-Bassat I, Gan S, Trakhtenbrot L, Mark Z, Ashur-Fabian O, Itskovich S, Brok-Simoni F, Rechavi G, Amariglio N, Nagler A. Assessment of the response to imatinib in chronic myeloid leukemia patients - comparison between the FISH, multiplex and RT-PCR methods. Eur J Haematol 2004; 73:243-50. [PMID: 15347310 DOI: 10.1111/j.1600-0609.2004.00287.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the kinetics of molecular response in chronic myeloid leukemia (CML) patients treated with imatinib and to compare between the fluorescent in situ hybridization (FISH), multiplex and real-time quantitative RT-PCR (RQ-PCR) methods with this respect. METHODS Molecular follow-up was carried out on 24 CML patients treated with imatinib. FISH analysis was performed according to the standard protocol. For RT-PCR the multiplex and RQ-PCR methods were used. RESULTS Sixty-three percent and 52% of the patients achieved complete remission according to FISH and multiplex RT-PCR analyses, respectively. Seventy-five percent of the patients achieved remission within the first year of treatment. In 83% of the cases the FISH and RT-PCR results were concordant. RQ-PCR analysis was carried out on 32 of the 41 samples negative by multiplex RT-PCR but only nine were negative. All samples with a BCR-ABL/ABL ratio below 2% were also negative by FISH. There was an excellent correlation between the RQ-PCR and the FISH tests. CONCLUSIONS Molecular remission according to FISH and multiplex RT-PCR can be achieved by imatinib within 1 yr of therapy. There is a good correlation between the FISH, multiplex and RQ-PCR results in terms of the kinetics of disappearance of the BCR-ABL transcript and the predictability of each method for the other. Although RQ-PCR is the most sensitive method for molecular follow-up, FISH and multiplex RT-PCR can be used as complementary tools, at least during the early period of treatment.
Collapse
MESH Headings
- Adult
- Aged
- Antineoplastic Agents/therapeutic use
- Benzamides
- Female
- Humans
- Imatinib Mesylate
- In Situ Hybridization, Fluorescence/methods
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Male
- Middle Aged
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Remission Induction
- Reverse Transcriptase Polymerase Chain Reaction/methods
Collapse
Affiliation(s)
- Pia Raanani
- The Institute of Hematology, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Avery S, Nadal E, Marin D, Olavarria E, Kaeda J, Vulliamy T, Brito Babapulle F, Goldman JM, Apperley JF. Lymphoid transformation in a CML patient in complete cytogenetic remission following treatment with imatinib. Leuk Res 2004; 28 Suppl 1:S75-7. [PMID: 15036946 DOI: 10.1016/j.leukres.2003.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Accepted: 10/29/2003] [Indexed: 11/26/2022]
Abstract
We describe here a patient with Philadelphia (Ph) chromosome-positive chronic myeloid leukemia who achieved a complete cytogenetic response following treatment with imatinib and then progressed abruptly to lymphoid blastic transformation. The sequence of events suggests that at least in some cases patients who respond well to imatinib may still harbor residual leukemia progenitor or 'stem' cells that are susceptible to acquisition of molecular events that underlie progression to advanced phase disease. The case highlights the need for molecular monitoring of responders and the need to develop strategies for reducing to a minimum or totally eradicating leukemia cells.
Collapse
Affiliation(s)
- S Avery
- Department of Haematology, Imperial College London at Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Thiede C, Bornhäuser M, Ehninger G. Strategies and clinical implications of chimerism diagnostics after allogeneic hematopoietic stem cell transplantation. Acta Haematol 2004; 112:16-23. [PMID: 15179000 DOI: 10.1159/000077555] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Analysis of donor chimerism has become a routine method for the documentation of engraftment after allogeneic hematopoietic stem cell transplantation (HSCT). In recent years several groups have also focused on the application of this technique for the detection of relapsing disease after allogeneic HSCT. This review addresses technical issues (sensitivity, specificity) and discusses the advantages and limitations of methods currently used for chimerism analysis and their usefulness for the detection of MRD. In addition, the potential impact of novel procedures, e.g. subset chimerism or real-time PCR-based procedures, is discussed.
Collapse
Affiliation(s)
- Christian Thiede
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität, Dresden, Germany.
| | | | | |
Collapse
|
35
|
van Dijk JP, de Witte T. Monitoring treatment efficiency in MDS at the molecular level; possibilities now and in the future. Leuk Res 2004; 28:101-8. [PMID: 14654071 DOI: 10.1016/s0145-2126(03)00186-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow (BM) diseases. MDS patients suffer from bone marrow failure because of the expansion of a malignant clone, resulting in abnormal differentiation of blood cells and severe pancytopenias. MDS patients have a high propensity for the development of acute myeloid leukemia (AML). During the last few years it has become increasingly clear that MDS is a stem cell disease. Two methods have generally been used to study the clonal origin of MDS bone marrow cells. First, the combination of fluorescent in situ hybridization (FISH) in combination with cell sorting has been used to study MDS specific numerical chromosomal aberrations in various cell types. Secondly, the determination of the X-chromosome inactivation patterns (XCIP) in different cell types of female MDS patients has been used to study clonality irrespective of the presence of a disease-specific marker. Both techniques have also been used to monitor treatment efficiency. Both methods showed that a molecular remission occurred in approximately half of the patients who achieved complete clinical remission after intensive antileukemic treatment, depending on the study and the type of treatment. In case of cytogenetic analysis this proved to be of prognostic significance. This review discusses the advantages and disadvantages of both techniques for the determination of clonality at diagnosis as well as for the assessment of treatment efficiency in past and in ongoing clinical trials. Future directions and possibilities for further research are also discussed.
Collapse
Affiliation(s)
- Jeroen P van Dijk
- Central Hematology Laboratory, University Medical Center Nijmegen, Nijmegen, The Netherlands
| | | |
Collapse
|
36
|
Abstract
The study of chronic myeloid leukemia has yielded many insights, especially after the discovery of the Ph chromosome, into the pathogenesis of leukemia and other forms of malignant disease. Most recently, knowledge of the central function of the BCR-ABL fusion gene led to the development of a small molecule, imatinib, that has proved remarkably effective at reducing the number of leukemia cells in individual CML patients and promises to prolong life substantially in comparison with earlier treatments. However, many questions relating to this exciting new agent remain unanswered, for example, how exactly it works, how patients develop resistance and what can be done to prevent or delay its onset, and whether any patient can really be "cured" by its use.
Collapse
MESH Headings
- Benzamides
- Drug Resistance, Neoplasm
- Drug Therapy, Combination
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- HSP70 Heat-Shock Proteins/immunology
- Hematopoietic Stem Cell Transplantation
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Mutation
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
Collapse
|
37
|
Response to Influence of stochastics on quantitative PCR in the detection of minimal residual disease by Rawer et al. Leukemia 2003. [DOI: 10.1038/sj.leu.2403192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
38
|
Sillaber C, Mayerhofer M, Agis H, Sagaster V, Mannhalter C, Sperr WR, Geissler K, Valent P. Chronic myeloid leukemia: pathophysiology, diagnostic parameters, and current treatment concepts. Wien Klin Wochenschr 2003; 115:485-504. [PMID: 13677268 DOI: 10.1007/bf03041033] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic myeloid leukemia (CML) is a stem cell disease characterized by excessive accumulation of clonal myeloid (precursor) cells in hematopoietic tissues. CML cells display the translocation t(9; 22) that creates the bcr/abl oncogene. The respective oncoprotein (= BCR/ABL) exhibits constitutive tyrosine kinase activity and promotes growth and survival in CML cells. Clinically, CML can be divided into three phases: the chronic phase (CP), the accelerated phase (AP), and the blast phase (BP) that resembles acute leukemia. Progression to AP and BP is associated with occurrence of additional genetic defects that cooperate with bcr/abl in leukemogenesis and lead to resistance against antileukemic drugs. The prognosis in CML is variable depending on the phase of disease, age, and response to therapy. The only curative approach available to date is stem cell transplantation. For those who cannot be transplanted, the BCR/ABL tyrosine kinase inhibitor STI571 (Glivec, Imatinib), interferon-alpha (with or without ARAC), or other cytoreductive drugs are prescribed. Currently available data show that STI571 is a superior compound compared to other drugs in producing complete cytogenetic and molecular responses. However, despite superior initial data and high expectations for an effect on survival, long term results are not available so far, and resistance against STI571 has been reported. Forthcoming strategies are therefore attempting to prevent or counteract STI571 resistance by co-administration of other antileukemic drugs. Whether these strategies will lead to curative drug therapy in CML in the future remains at present unknown.
Collapse
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibiotics, Antineoplastic/administration & dosage
- Antibiotics, Antineoplastic/therapeutic use
- Antimetabolites, Antineoplastic/administration & dosage
- Antimetabolites, Antineoplastic/therapeutic use
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Benzamides
- Bone Marrow Examination
- Clinical Trials as Topic
- Cytarabine/administration & dosage
- Cytarabine/therapeutic use
- Diagnosis, Differential
- Drug Resistance
- Enzyme Inhibitors/therapeutic use
- Female
- Fusion Proteins, bcr-abl
- Humans
- Imatinib Mesylate
- Immunophenotyping
- Interferon-alpha/administration & dosage
- Interferon-alpha/therapeutic use
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/etiology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/physiopathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Male
- Middle Aged
- Multivariate Analysis
- Piperazines/therapeutic use
- Prognosis
- Pyrimidines/therapeutic use
- Risk Factors
- Sirolimus/administration & dosage
- Sirolimus/therapeutic use
- Stem Cell Transplantation
- Time Factors
Collapse
Affiliation(s)
- Christian Sillaber
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, AKH-Wien, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Lin F, Drummond M, O'Brien S, Cervantes F, Goldman J, Kaeda J. Molecular monitoring in chronic myeloid leukemia patients who achieve complete cytogenetic remission on imatinib. Blood 2003; 102:1143. [PMID: 12869491 DOI: 10.1182/blood-2002-12-3916] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
40
|
Au WY, Ma SK, Kwong YL. The occurrence of Philadelphia chromosome (Ph) negative leukemia after hematopoietic stem cell transplantation for Ph positive chronic myeloid leukemia: implications for disease monitoring and treatment. Leuk Lymphoma 2003; 44:1121-9. [PMID: 12916863 DOI: 10.1080/1042819031000079104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Chronic myeloid leukemia (CML) is a clonal neoplastic disorder, characterized by t(9;22)(q34;q11) that results in the formation of the Philadelphia chromosome (Ph) and the BCR/ABL fusion gene. Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for CML. Much of its therapeutic efficacy is attributed to a graft-versus-leukemia (GVL) effect exerted by donor-derived lymphoid cells against the Ph positive (Ph+) clone. Post-HSCT monitoring by cytogenetic and molecular detection of the Ph+ clone is necessary, so that pre-emptive immunologic or pharmacologic treatment may be administered at an early stage of relapse. However, under rare circumstances a second Ph negative (Ph-) leukemia may evolve post-HSCT. The pathogenetic possibilities included leukemia arising from donor-derived hematopoietic stem cells (HSCs), or transformation of residual recipient-derived Ph- HSCs that have survived the conditioning chemotherapy and radiotherapy. Recipient-derived Ph- leukemia may be related to genetic alterations that precede the onset of CML, or myelotoxic effects of the HSCT conditioning regimen. The diagnosis of Ph- relapses requires detailed investigations by conventional karyotyping, fluorescence in-situ hybridization (FISH), and molecular analysis; as well as chimerism studies that help to document the donor or recipient origin of the leukemia. Although uncommonly reported in the past, Ph- relapses may in fact be more frequent if leukemic relapses post-HSCT are more thoroughly evaluated with these investigations. The recognition of Ph- relapses are important in several ways. Ph- relapses cannot be identified by monitoring investigations targeting the Ph+ clone, so that the early detection of Ph- leukemia is usually not possible. Furthermore, Ph- relapses will not respond to therapeutic strategies effective against the Ph+ CML clone.
Collapse
MESH Headings
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/etiology
Collapse
Affiliation(s)
- W Y Au
- University Department of Medicine, Queen Mary Hospital, Hong Kong, People's Republic of China
| | | | | |
Collapse
|
41
|
Kaeda J, Apperley J, Melo J, Cross N, Goldman J. Monitoring CML after nonmyeloablative transplantations: how negative is negative? Blood 2003; 101:5084; author reply 5084-5. [PMID: 12788790 DOI: 10.1182/blood-2003-01-0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
42
|
Goldman JM, Marin D, Olavarria E, Apperley JF. Clinical decisions for chronic myeloid leukemia in the imatinib era. Semin Hematol 2003; 40:98-103; discussion 104-13. [PMID: 12783383 DOI: 10.1053/shem.2003.50049] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Imatinib is clearly an important contribution to the management of patients with chronic myeloid leukemia (CML). Based on the available data, it seems reasonable to conclude that this exciting new agent is the best primary treatment for the newly diagnosed chronic-phase patient who is not immediately eligible for allogeneic stem cell transplant (allo-SCT). However, the definition of response or failure to respond is not straightforward and the extent to which imatinib prolongs life when used as a single agent cannot yet be estimated with any accuracy. This means that decisions on how best to continue treatment can be extremely difficult. Moreover, the decision whether and when to offer the patient treatment by allo-SCT has become especially complicated in the last 2 years. Imatinib seems to be generally less effective when used to treat patients in advanced phases of CML, although some patients treated in accelerated phase may achieve prolonged disease control. It is likely that the role of imatinib, used alone or in combination with other agents, will be more clearly defined in the near future.
Collapse
Affiliation(s)
- John M Goldman
- Department of Haematology, Imperial College London at Hammersmith Hospital, London, UK
| | | | | | | |
Collapse
|
43
|
Hall GW. Cytogenetic and molecular genetic aspects of childhood myeloproliferative/myelodysplastic disorders. Acta Haematol 2003; 108:171-9. [PMID: 12432214 DOI: 10.1159/000065654] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Of the myeloproliferative/myelodysplastic disorders (MPD/MDS) that occur in childhood most, regarding the cytogenetic and molecular genetic basis, is known about the two purely paediatric disorders: juvenile myelomonocytic leukaemia (JMML) and transient myeloproliferative disorder (TMD). Although much has been published about these two disorders, their aetiology is by no means fully established. It would appear, however, that in this paediatric subset of MPDs a stage/developmentally specific vulnerability for proliferation and transformation exists. The study of the molecular basis of many other MPD-like syndromes that also occur in childhood, has been greatly accelerated by the identification of rare, but recurring, cytogenetic abnormalities involving 8p11 and 5q31-33. Good collaborative studies could result in similar progress being made in the understanding of JMML and TMD.
Collapse
Affiliation(s)
- Georgina W Hall
- Paediatric Haematology/Oncology Unit, John Radcliffe Hospital, Oxford, UK.
| |
Collapse
|
44
|
|