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Tang K, Lipton JH. Stem cell allografting for chronic Myeloid leukemia in the tyrosine kinase era - forgotten but not gone. Leuk Lymphoma 2024; 65:705-714. [PMID: 38335007 DOI: 10.1080/10428194.2024.2313626] [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: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
Due to the remarkable success of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML), allogeneic stem cell transplantation (alloSCT) is not first-line treatment for delivering durable, long-term survival. Consequently, alloSCT is reserved for patients with TKI-resistant or TKI-intolerant chronic phase CML (CP-CML) and advanced phase CML (AP-CML). Advances in transplant technology, such as high-resolution HLA typing, introduction of reduced intensity conditioning and increased alternative donor availability, coupled with improved supportive care, have significantly reduced transplant-related mortality and expanded the pool of transplant-eligible patients. Refinement of conditioning regimens, innovative use of post-transplant cellular and pharmacological therapies, and judicious post-transplant monitoring are important strategies for reducing risk of relapse. Given its potential to cure, alloSCT will invariably remain a key part of the treatment algorithm. This article reviews the data underpinning the role and outcomes of alloSCT and provides an update on current recommendations.
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Affiliation(s)
- Kenny Tang
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Haematology, Blacktown Hospital, New South Wales, Australia
| | - Jeffrey H Lipton
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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2
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Niederwieser C, Kröger N. Transplantation in CML in the TKI era: who, when, and how? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:114-122. [PMID: 36485123 PMCID: PMC9820642 DOI: 10.1182/hematology.2022000329] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Molecular therapy with tyrosine kinase inhibitors (TKIs) has significantly reduced the indication for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in chronic myeloid leukemia (CML). Treatment-free remission can be obtained in about 50% of patients with an optimal response. However, cure rates up to 90% are restricted to patients receiving HSCT. Timing is essential since HSCT in the early stages of the disease has the best outcome. Patients in a more advanced phase (AdP) than chronic-phase (chP) CML undergo HSCT with suboptimal outcomes, and the gap between chP and AdP disease is widening. First-line therapy should start with first- or second-generation (G) TKIs. Patients failing treatment (BCR-ABL1 transcripts of greater than 10% at 3 and 6 months and greater than 1% at 12 months) should be switched to second-line TKIs, and HSCT should be considered. Patients not responding to 2G-TKI therapy as well as patients in an accelerated phase (AP) or blast crisis (BC) are candidates for HSCT. Therapy resistant BCR-ABL1 mutations, high-risk additional cytogenetic abnormalities, and molecular signs of leukemia progression should trigger the indication for HSCT. Patients who, despite dose adjustments, do not tolerate or develop severe adverse events, including vascular events, to multiple TKIs are also candidates for HSCT. In AdP CML, TKIs do not show long-lasting results, and the outcome of HSCT is less optimal without pretransplant therapy. In these patients the induction of chP2 with TKIs, either alone (AP) or in combination with intensive chemotherapy (BC), followed by HSCT should be pursued.
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Affiliation(s)
- Christian Niederwieser
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
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3
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Shanmuganathan N, Branford S. Multiplex technologies for the assessment of minimal residual disease and low-level mutation detection in leukaemia: mass spectrometry versus next-generation sequencing. Br J Haematol 2021; 196:19-30. [PMID: 34124782 DOI: 10.1111/bjh.17623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 01/07/2023]
Abstract
With the focus of leukaemia management shifting to the implications of low-level disease burden, increasing attention is being paid on the development of highly sensitive methodologies required for detection. There are various techniques capable of identification of measurable residual disease (MRD) either evidencing as relevant mutation detection [e.g. nucleophosmin 1 (NPM1) mutation] or trace levels of leukaemic clonal populations. The vast majority of these methods only permit detection of a single clone or mutation. However, mass spectrometry and next-generation sequencing enable the interrogation of multiple genes simultaneously, facilitating a more complete genomic profile. In the present review, we explore the methodologies of both techniques in conjunction with the important advantages and limitations associated with each assay. We also highlight the evidence and the various instances where either technique has been used and propose future strategies for MRD detection.
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Affiliation(s)
- Naranie Shanmuganathan
- Department of Haematology, Royal Adelaide Hospital and SA Pathology, Adelaide, South Australia, Australia.,Department of Genetics and Molecular Pathology and Centre for Cancer Biology, SA Pathology, Adelaide, South Australia, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.,School of Pharmacy and Medical Science, University of South Australia, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Susan Branford
- Department of Genetics and Molecular Pathology and Centre for Cancer Biology, SA Pathology, Adelaide, South Australia, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.,School of Pharmacy and Medical Science, University of South Australia, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Late molecular recurrences in patients with chronic myeloid leukemia experiencing treatment-free remission. Blood Adv 2021; 4:3034-3040. [PMID: 32614963 DOI: 10.1182/bloodadvances.2020001772] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 01/15/2023] Open
Abstract
Treatment-free remission (TFR) is an opportunity for patients with chronic myeloid leukemia (CML). Reported cumulative incidence curves of molecular recurrence (MRec) arbor a 2-phase shape with mainly early events, but also some late events (late MRec [LMRec]). Having discontinued our first patient in 2004, we have access to a prolonged follow-up, enabling us to characterize these late events. Over 15 years, 128 patients from our institution were registered in the Stop Imatinib (STIM; A Study for Tyrosine Kinase Inhibitors Discontinuation [A-STIM]) trial. MRec was defined by the loss of major molecular response (BCR-ABL1IS >0.1%). At the first TFR attempt, patients had been taking a tyrosine kinase inhibitor for a median of 7.1 years and in BCR-ABL1IS ≤0.01% (MR4) for a median of 4 years. The median follow-up of patients in TFR was 6.5 years. The TFR rate was estimated to be 45.6% after 7 years. For 9/65 (14%) patients experiencing MRec, recurrence occurred after 2 years in TFR (median, 3.6 years). The residual rate of MRec after 2 years was estimated to be 18%. The probability of remaining in TFR was 65.4% for patients having experienced fluctuations of their minimal residual disease (MRD) (at least 2 consecutive measurements BCR-ABL1IS >0.0032% or loss of MR4), whereas it was 100% for those with stable MRD (P = .003). After 2 years in TFR, we observed an 18% residual rate of LMRec. These late events represent 14% of all MRec and occur in patients with fluctuating MRD measurements. A long-term molecular follow-up therefore remains mandatory for CML patients in TFR. The A-STIM study was registered at www.clinicaltrials.gov as #NCT02897245.
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5
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Okuku P, Kwenda G, Samutela M, Nkhoma P, Mantina H. Molecular Detection of Fusion Oncogenes in Zambian Patients with Acute Lymphoblastic Leukemia. Int J Appl Basic Med Res 2020; 10:234-239. [PMID: 33376695 PMCID: PMC7758799 DOI: 10.4103/ijabmr.ijabmr_179_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 05/25/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Chromosomal aberrations play a significant role in the pathogenesis of acute lymphoblastic leukemia (ALL) with prognostic and therapeutic implications. Despite the availability of molecular tools, low-resource settings struggle to diagnose the disease due to limited diagnostic capacity. The objective of this study was to detect common chromosomal aberrations in patients with ALL attending the University Teaching Hospital (UTH) in Lusaka, Zambia. Materials and Methods In this prospective study, 19 blood samples from patients with ALL were screened for the presence of BCR-ABL, E2A-PBX1, MLL-AF4, and ETV6-RUNX1 fusion oncogenes using reverse transcriptase-polymerase chain reaction assay. Blood counts and clinical characteristics of patients were also assessed. Results The age of patients ranged from 1½ to 72 years and comprised 57.9% of males and 42.1% of females. The majority of these patients were children (68%), and adults only comprised 32%. Only BCR-ABL and E2A-PBX1 oncogenes were detected in 3/19 of cases. The BCR-ABL gene was detected in a 4-year-old female child and a 15-year-old child. Both cases were associated with hepatomegaly and anemia coupled with low hemoglobin, white blood cell, and platelet counts. E2A-PBX1 was detected in a 12-year-old child with lymphadenopathy and splenomegaly, coupled with low hemoglobin, white blood cell, and platelet counts. All the three patients who harbored these fusion oncogenes died. Conclusion This is the first study from Zambia to investigate the presence of fusion oncogenes in leukemia patients, which were found only among the older children population. Based on these findings, we recommend that molecular diagnosis be made a priority for the younger leukemia patient population at UTH.
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Affiliation(s)
- Pauline Okuku
- Department of Pathology and Microbiology, School of Medicine, University of Zambia, Lusaka, Zambia.,Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Geoffrey Kwenda
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Mulemba Samutela
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Panji Nkhoma
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Hamakwa Mantina
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
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Molica M, Noguera NI, Trawinska MM, Martinelli G, Cerchione C, Abruzzese E. Treatment free remission in chronic myeloid leukemia: Lights and shadows. Hematol Rep 2020; 12:8950. [PMID: 33042501 PMCID: PMC7520857 DOI: 10.4081/hr.2020.8950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 01/03/2023] Open
Abstract
In addition to the best possible overall survival, discontinuation of the tyrosine kinase-inhibitor (TKI) treatment [treatment free remission (TFR)] without observing a recurrence of the disease has become a standard part of chronic myeloid leukemia (CML) care. Worldwide, more than 2000 patients with CML have attempted TFR, and very rare instances of disease transformation have been reported. Several studies in the last decade have demonstrated the feasibility and safety of TKI discontinuation in selected patients with CML who achieve deep and sustained molecular response with TKI. This has moved prime-time into clinical practice although open questions remain in terms of understanding the disease biology that leads to successful TKI cessation in some patients while not in others. Despite the remaining questions regarding which factors may be considered predictive for TFR, treatment interruption is a safe option provided that adequate molecular monitoring is available, with prompt re-initiation of TKIs as soon as major molecular response has been lost. Data from ongoing trials should help refine decisions as to which patients are the best candidates to attempt TKI discontinuation, frequency of a safe monitoring, optimal strategies to sustain ongoing TFR and increase the number of patients who can access to discontinuation programs.
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Affiliation(s)
| | - Nelida I Noguera
- Department of Biomedicine and Prevention, Tor Vergata University of Rome
| | | | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
| | - Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
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Harrington P, Radia D, de Lavallade H. What are the considerations for tyrosine kinase inhibitor discontinuation in chronic-phase chronic myeloid leukemia? Expert Rev Hematol 2020; 13:213-222. [PMID: 31952452 DOI: 10.1080/17474086.2020.1717944] [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] [Indexed: 01/28/2023]
Abstract
Introduction: The outlook for patients with chronic myeloid leukemia (CML) has changed dramatically with the development of tyrosine kinase inhibitors (TKIs) with the current treatment goal for many patients being to obtain a durable deep molecular remission, discontinue TKI therapy, and remain treatment free.Areas covered: In this article, the authors review the data from the major TKI discontinuation studies, explore potential predictors of discontinuation outcome and look at possible mechanisms to explain the variable outcomes following TKI discontinuation including immune surveillance and leukemic stem cell (LSC) depletion following TKI treatment. Data from relevant articles published on the Pubmed database between January 2007 and January 2020 have been included.Expert opinion: The results from the majority of TKI discontinuation studies show a consistent picture with approximately half of eligible patients achieving treatment free remission (TFR). However, reliable clinical predictors or biomarkers for the outcome of TKI discontinuation remain elusive and the mechanisms to explain the diversity of discontinuation success are not completely understood. Future studies will need to focus on attempts to increase the number of patients eligible for treatment discontinuation and will likely involve drug combinations including novel agents aimed at targeting the residual LSC population and enhancement of immune surveillance mechanisms.
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Affiliation(s)
- Patrick Harrington
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK.,Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Deepti Radia
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | - Hugues de Lavallade
- Department of Haematological Medicine, King's College London School of Medicine, London, UK.,Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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Chronic Myeloid Leukemia Relapsing 25 Years after Allogenic Stem Cell Transplantation. Case Rep Hematol 2018; 2018:2045985. [PMID: 30345125 PMCID: PMC6174736 DOI: 10.1155/2018/2045985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/15/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disorder in which neoplastic cells exhibit the Philadelphia chromosome and the related oncoprotein BCR-ABL1. Allogeneic stem cell transplantation (allo-SCT) was considered the first-line treatment for CML, before the introduction of tyrosine kinase inhibitors (TKIs). However, patients are at risk for relapse years after transplantation. We present a patient who relapsed 25 years after allo-SCT for chronic phase CML. Polymerase chain reaction (PCR) detected gradually evaluated levels of BCR-ABL1 transcripts, eventually leading to the diagnosis of relapsed disease. Additional mutational analyses did not reveal mutations in the BCR-ABL1 gene, or other cooperating mutations. The patient was successfully treated with imatinib 400 mg daily, leading to new molecular remission. The case presentation emphasizes the need for long-term follow-up of such patients and the potential benefit of initiating TKI treatment with early signs of relapse.
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9
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Mahon FX. Treatment-free remission in CML: who, how, and why? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:102-109. [PMID: 29222243 PMCID: PMC6142562 DOI: 10.1182/asheducation-2017.1.102] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Chronic myeloid leukemia (CML) is the best example of successful targeted therapy. Today, the overall survival of patients with CML treated by using tyrosine kinase inhibitors (TKIs) is very close to that of the healthy population. The current question is: how can we further ameliorate the clinical outcome of patients with CML? Clinical trials have shown that some patients with CML in the chronic phase who achieve sustained deep molecular responses on TKI therapy can safely suspend therapy with no evidence of relapse. The long follow-up studies and the number of eligible patients have now validated the concept of treatment-free remission (ie, the ability to maintain a molecular response after stopping therapy). It should be considered as the future criterion to evaluate the success of clinical trials, especially if we want to take into account the quality of life of patients in addition to the economic aspect. Because post-TKI discontinuation follow-ups have been increasing over time with no evidence of relapse in some patients, the next step for the coming decade will be to address the topic of CML cure.
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Affiliation(s)
- Francois-Xavier Mahon
- Institut Bergonié, Cancer Centre, Laboratory of Mammary and Leukemic Oncogenesis: Genetic Diversity and Resistance to Treatment, INSERM U1218, University of Bordeaux, Bordeaux, France
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10
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Abstract
Abstract
Chronic myeloid leukemia (CML) is the best example of successful targeted therapy. Today, the overall survival of patients with CML treated by using tyrosine kinase inhibitors (TKIs) is very close to that of the healthy population. The current question is: how can we further ameliorate the clinical outcome of patients with CML? Clinical trials have shown that some patients with CML in the chronic phase who achieve sustained deep molecular responses on TKI therapy can safely suspend therapy with no evidence of relapse. The long follow-up studies and the number of eligible patients have now validated the concept of treatment-free remission (ie, the ability to maintain a molecular response after stopping therapy). It should be considered as the future criterion to evaluate the success of clinical trials, especially if we want to take into account the quality of life of patients in addition to the economic aspect. Because post-TKI discontinuation follow-ups have been increasing over time with no evidence of relapse in some patients, the next step for the coming decade will be to address the topic of CML cure.
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11
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Rea D, Mahon FX. How I manage relapse of chronic myeloid leukaemia after stopping tyrosine kinase inhibitor therapy. Br J Haematol 2017; 180:24-32. [PMID: 29048128 DOI: 10.1111/bjh.14973] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
During the last 10 years, clinical trials formally demonstrated that about 50% of patients with chronic phase (CP) chronic myeloid leukaemia (CML) who achieve and maintain deep molecular responses for a prolonged period of time during treatment with imatinib or new generation tyrosine kinase inhibitors (TKIs) may successfully stop their anti-leukaemic therapy. Based on the accumulated knowledge from abundant clinical trial experience, TKI discontinuation is becoming an important goal to achieve and is about to enter clinical practice. This review focuses on relapse definition, laboratory tests to identify relapse and relapse management after TKI discontinuation.
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Affiliation(s)
- Delphine Rea
- Service d'hématologie Adulte, Unité INSERM, UMR-1160 and France Intergroupe des Leucémies Myéloïdes Chroniques (Fi-LMC), Hôpital Saint-Louis, Paris, France
| | - François-Xavier Mahon
- Unicancer Center, Institut Bergonié and France Intergroupe des Leucémies Myéloïdes Chroniques (Fi-LMC), Bordeaux, France
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12
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Lee SE, Choi SY, Kim SH, Song HY, Yoo HL, Lee MY, Kang KH, Hwang HJ, Jang EJ, Kim DW. BCR-ABL1 transcripts (MR 4.5) at post-transplant 3 months as an early predictor for long-term outcomes in chronic myeloid leukemia. Korean J Intern Med 2017; 32:125-136. [PMID: 27334764 PMCID: PMC5214723 DOI: 10.3904/kjim.2015.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 07/23/2015] [Accepted: 08/04/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to identify the role of BCR-ABL1 transcript level as a predictor for post-transplant relapse and outcome in patients who underwent allogeneic stem cell transplantation (SCT) for chronic phase (CP) chronic myeloid leukemia (CML). METHODS Of 101 patients receiving allograft in CML CP, 85 had available quantitative reverse transcriptase polymerase chain reaction data at post-transplant 3 months. These patients were divided into two groups according to molecular response (MR4.5), defined as a BCR-ABL1 transcript level ≤ 0.0032% on the international scale, at 3 months based on receiver operating characteristic curve analysis of relapse. RESULTS The 4-year overall survival and event-free survival (EFS) were 80.6% and 57.3%, respectively, and the cumulative incidence of relapse at 4 years was 29.6% after a median follow-up of 126.4 months. We performed multivariate analyses including potential variables to evaluate the early predictive role of MR4.5 at 3 months and found that MR4.5 at 3 months was associated with a higher EFS (p = 0.028) and showed a trend for a lower relapse rate (p = 0.089). CONCLUSIONS our results imply that frequent molecular monitoring and immune suppressive therapy modulation are required for patients without reduction of BCR-ABL1 transcripts to this level after SCT.
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MESH Headings
- Adolescent
- Adult
- Area Under Curve
- Biomarkers, Tumor/genetics
- Disease-Free Survival
- Drug Therapy, Combination
- Female
- Fusion Proteins, bcr-abl/genetics
- Graft vs Host Disease/etiology
- Humans
- Immunosuppressive Agents/therapeutic use
- Kaplan-Meier Estimate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/surgery
- Male
- Middle Aged
- Multivariate Analysis
- Predictive Value of Tests
- Proportional Hazards Models
- ROC Curve
- Recurrence
- Reverse Transcriptase Polymerase Chain Reaction
- Risk Factors
- Stem Cell Transplantation/adverse effects
- Stem Cell Transplantation/mortality
- Time Factors
- Transplantation, Homologous
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Sung-Eun Lee
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
- Department of Hematology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Soo Young Choi
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Soo-Hyun Kim
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Hye-Young Song
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Hea-Lyun Yoo
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Mi-Young Lee
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Ki-Hoon Kang
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Hee-Jeong Hwang
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jung Jang
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Dong-Wook Kim
- Catholic Leukemia Research Institute, The Catholic University of Korea, Seoul, Korea
- Department of Hematology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Dong-Wook Kim, M.D. Department of Hematology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-7030 Fax: +82-2-593-2522 E-mail:
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Kim SH. The role of early molecular predictor in transplant-eligible chronic myelogenous leukemia. Korean J Intern Med 2017; 32:67-68. [PMID: 28049288 PMCID: PMC5214737 DOI: 10.3904/kjim.2016.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/23/2016] [Indexed: 11/27/2022] Open
Affiliation(s)
- Sung-Hyun Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
- Correspondence to Sung-Hyun Kim, M.D. Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, 26 Daesingongwon-ro, Seo-gu, Busan 49201, Korea Tel: +82-51-240-2608 Fax: +82-51-246-5044 E-mail:
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Hehlmann R, Saußele S, Voskanyan A, Silver RT. Management of CML-blast crisis. Best Pract Res Clin Haematol 2016; 29:295-307. [PMID: 27839570 DOI: 10.1016/j.beha.2016.10.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/10/2016] [Indexed: 12/28/2022]
Abstract
Tyrosine kinase inhibitors (TKI) have moderately improved survival in BC, but a median survival of less than 1 year is still unsatisfactory. This article reviews the various tests required for diagnosis of BC, features at diagnosis, treatment modalities (intensive chemotherapy, TKI, allo-SCT and a selection of investigational agents), options of prevention and predictors of progression. The best prognosis is observed in patients that achieve a 2nd CP. Allo-SCT probably further improves prognosis of patients in 2nd CP. The choice of TKI should be directed by the mutation profile of the patient. BC can be prevented. A careful analysis of risk factors for progression may help. Current treatment options are combined in a concluding strategy for the management of BC.
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Affiliation(s)
- Rüdiger Hehlmann
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Susanne Saußele
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Astghik Voskanyan
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Richard T Silver
- Division of Hematology/Medical Oncology, Weill Cornell Medical College, New York, NY, USA.
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Discontinuation of TKI therapy and 'functional' cure for CML. Best Pract Res Clin Haematol 2016; 29:308-313. [PMID: 27839571 DOI: 10.1016/j.beha.2016.10.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 11/20/2022]
Abstract
Stopping tyrosine kinase inhibitor (TKI) therapy after achieving a sustained deep molecular response is an emerging treatment goal for patients with chronic myeloid leukaemia in chronic phase (CML-CP). Indeed, the feasibility of stopping TKI therapy has been confirmed in various studies. The Stop Imatinib 1 (STIM1) study has shown a consistent follow-up which allowed defining a new criterion of clinical outcome evaluation, the treatment free remission (TFR). However, announcing a definitive cure remains a challenge owing to the discovery that TKIs spare quiescent leukaemic stem cells (LSC). It is definitely known that even a patient in long-term TFR has persistent LSCs. For this reason, a "functional" cure has been defined and proposed.
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16
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Dulucq S, Mahon FX. Deep molecular responses for treatment-free remission in chronic myeloid leukemia. Cancer Med 2016; 5:2398-411. [PMID: 27367039 PMCID: PMC5055167 DOI: 10.1002/cam4.801] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/13/2016] [Accepted: 05/22/2016] [Indexed: 12/29/2022] Open
Abstract
Several clinical trials have demonstrated that some patients with chronic myeloid leukemia in chronic phase (CML-CP) who achieve sustained deep molecular responses on tyrosine kinase inhibitor (TKI) therapy can safely suspend therapy and attempt treatment-free remission (TFR). Many TFR studies to date have enrolled imatinib-treated patients; however, the feasibility of TFR following nilotinib or dasatinib has also been demonstrated. In this review, we discuss available data from TFR trials and what these data reveal about the molecular biology of TFR. With an increasing number of ongoing TFR clinical trials, TFR may become an achievable goal for patients with CML-CP.
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Affiliation(s)
- Stéphanie Dulucq
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Francois-Xavier Mahon
- Bergonié Cancer Institute, INSERM Unit 916, University of Bordeaux, Bordeaux, France.
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17
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Hosseini S, Ansari S, Vosough P, Bahoush G, Hamidieh AA, Chahardouli B, Shamsizadeh M, Mehrazma M, Dorgalaleh A. Bilateral Maxillary, Sphenoid Sinuses and Lumbosacral Spinal Cord Extramedullary Relapse of CML Following Allogeneic Stem Cell Transplant. Int J Hematol Oncol Stem Cell Res 2016; 10:106-10. [PMID: 27252811 PMCID: PMC4888147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Isolated extramedullary relapse of chronic myelogenous leukemia (CML) after allogeneic stem cell transplant is rare. There is a case report of a child who developed a granulocytic sarcoma of the maxillary and sphenoid sinuses and lumbosacral spinal cord mass 18 months after allogeneic bone marrow transplant for CML. He was presented with per orbital edema and neurological deficit of lower extremities and a mass lesion was found on spinal cord imaging. No evidence of hematologic relapse was identified at that time by bone marrow histology or cytogenetic. The patient died 1 month later with a picture of pneumonia, left ventricular dysfunction and a cardiopulmonary arrest on a presumed underlying sepsis with infectious etiology. Granulocytic sarcoma should be considered in the differential diagnosis of mass lesions presenting after allogeneic bone marrow transplantation for CML, even if there is no evidence of bone marrow involvement.
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Affiliation(s)
- Soudabeh Hosseini
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Shahla Ansari
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Vosough
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Bahoush
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ali Hamidieh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Chahardouli
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Shamsizadeh
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mitra Mehrazma
- Department of Pathology, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
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18
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Management of Elderly Patients with Newly Diagnosed Chronic Myeloid Leukemia in the Accelerated or Blastic Phase. Drugs Aging 2016; 33:335-45. [PMID: 26961697 DOI: 10.1007/s40266-016-0351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the elderly population, the accelerated and blastic phases of chronic myeloid leukemia (CML) are difficult to treat, not just because of the higher chance of acquired mutations than in younger individuals, but because of additional associated co-morbidities. Tyrosine kinase inhibitors are well-established in the treatment of the chronic phase of CML, and their use in advanced phases is ever-increasing. Elderly patients who are still eligible candidates for transplant can undergo reduced-intensity transplants from related or unrelated donors after reverting to chronic phase. Post-transplantation, these patients require adequate monitoring and therapy to prevent relapses. Newer modalities of treatment or interventions are urgently required in this complex group of patients.
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19
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DeFilipp Z, Khoury HJ. Management of advanced-phase chronic myeloid leukemia. Curr Hematol Malig Rep 2016; 10:173-81. [PMID: 25929768 DOI: 10.1007/s11899-015-0249-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The management of chronic myeloid leukemia (CML) in accelerated or blast phase (advanced phase) remains a significant challenge despite the introduction of very effective tyrosine kinase inhibitors (TKIs). The biology of advanced-phase CML is complex and engages several pathways that are not optimally targeted by TKIs. Allogeneic stem cell transplantation remains the only potentially curative therapy, but the effectiveness of this conventional approach is limited. New strategies are required to improve the outlook for these patients.
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Affiliation(s)
- Zachariah DeFilipp
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road NE C5010, Atlanta, GA, 30322, USA,
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20
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Abstract
The management of chronic myeloid leukaemia (CML) has changed extensively over the past 15 years. Prior to the development of targeted therapies and in the absence of allogeneic haematopoetic stem-cell transplantation (HSCT), the median survival was 5-7 years. HSCT was quickly established as the standard of care for eligible patients through the 1980s and 1990s, when considerable advances were made in the optimization of conditioning regimens and supportive care. Exploiting a deeper understanding of the molecular basis of CML, the development of tyrosine kinase inhibitors (TKIs) in the late 1990s revolutionized the management of the disease. TKIs offer the prospect of long-term disease control with a simple oral therapy, and are the first-line treatment in the 21(st) century. The majority of patients treated with TKIs achieve excellent responses with sustained treatment, and some even continue to have undetectable or exceptionally low level disease upon TKI withdrawal; however, for an almost equal number of patients, an adequate response cannot be achieved with any of the currently available TKIs. For those patients who fail to respond adequately to TKIs, HSCT offers the best prospect of long-term survival.
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21
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Yong ASM, Brissot E, Rubinstein S, Savani BN, Mohty M. Transplant to treatment-free remission: the evolving view of ‘cure’ in chronic myeloid leukemia. Expert Rev Hematol 2015; 8:785-97. [DOI: 10.1586/17474086.2015.1087843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Koren-Michowitz M, Shimoni A, Daraio F, Crasto F, Lorenzatti R, Volchek Y, Amariglio N, Gottardi E, Saglio G, Nagler A. Sensitive Replicate Real-Time Quantitative PCR of BCR-ABL Shows Deep Molecular Responses in Long-Term Post-Allogeneic Stem Cell Transplantation Chronic Myeloid Leukemia Patients. Biol Blood Marrow Transplant 2015; 21:1852-5. [PMID: 26151304 DOI: 10.1016/j.bbmt.2015.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/20/2015] [Indexed: 11/30/2022]
Abstract
Real-time quantitative PCR (RT-qPCR) is commonly used for follow-up of chronic myeloid leukemia (CML) patients treated with tyrosine kinase inhibitors, but its current sensitivity does not allow detection of very low BCR-ABL levels. Therefore RT-qPCR negativity is not synonymous with complete molecular response. Replicate RT-qPCR had shown increased sensitivity in tyrosine kinase inhibitor-treated patients and was, therefore, used here to evaluate whether RT-qPCR-negative post-allogeneic stem cell transplantation (SCT) patients harbor detectable disease. Samples from 12 patients were tested at 2 time points using 82 replicates of BCR-ABL RT-qPCR. One patient (38 months after SCT) had detectable transcripts at baseline and none at the follow-up test, done at a median of 107 months after SCT. This suggests cure from CML in the majority of allogeneic SCT patients who have no transcripts detectable by replicate RT-qPCR for BCR-ABL.
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Affiliation(s)
- Maya Koren-Michowitz
- Division of Hematology, Chaim Sheba Medical Center Tel Hashomer, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Avichai Shimoni
- Division of Hematology, Chaim Sheba Medical Center Tel Hashomer, Ramat-Gan, Israel
| | - Filomena Daraio
- Division of Hematology and Internal Medicine, Department of Clinical and Biological Sciences of the University of Turin, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Francesca Crasto
- Division of Hematology and Internal Medicine, Department of Clinical and Biological Sciences of the University of Turin, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Roberta Lorenzatti
- Division of Hematology and Internal Medicine, Department of Clinical and Biological Sciences of the University of Turin, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Yulia Volchek
- Division of Hematology, Chaim Sheba Medical Center Tel Hashomer, Ramat-Gan, Israel
| | - Ninette Amariglio
- Division of Hematology, Chaim Sheba Medical Center Tel Hashomer, Ramat-Gan, Israel
| | - Enrico Gottardi
- Division of Hematology and Internal Medicine, Department of Clinical and Biological Sciences of the University of Turin, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Giuseppe Saglio
- Division of Hematology and Internal Medicine, Department of Clinical and Biological Sciences of the University of Turin, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center Tel Hashomer, Ramat-Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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The role of stem cell transplantation for chronic myelogenous leukemia in the 21st century. Blood 2015; 125:3230-5. [PMID: 25852053 DOI: 10.1182/blood-2014-10-567784] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 03/21/2015] [Indexed: 12/13/2022] Open
Abstract
The introduction of tyrosine kinase inhibitors (TKIs), a treatment of chronic myelogenous leukemia (CML), has largely replaced curative strategies based on allogeneic stem cell transplantation (SCT). Nevertheless, SCT still remains an option for accelerated/blastic-phase and selected chronic-phase CML. Transplant outcomes can be optimized by peritransplant TKIs, conditioning regimen, BCR-ABL monitoring, and relapse management. Controversies exist in transplant timing, pediatric CML, alternative donors, and economics. SCT continues to serve as a platform of "operational cure" for CML with TKIs and immunotherapies.
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24
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Kaeda J, Ringel F, Oberender C, Mills K, Quintarelli C, Pane F, Koschmieder S, Slany R, Schwarzer R, Saglio G, Hemmati P, van Lessen A, Amini L, Gresse M, Vagge E, Burmeister T, Serra A, Carson A, Schwarz M, Westermann J, Jundt F, Dörken B, le Coutre P. Up-regulated MSI2 is associated with more aggressive chronic myeloid leukemia. Leuk Lymphoma 2015; 56:2105-13. [PMID: 25363400 DOI: 10.3109/10428194.2014.981175] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A better understanding of events triggering chronic myeloid leukemia progression is critical for optimized clinical management of chronic myeloid leukemia (CML). We sought to validate that increased expression of Musashi 2 (MSI2), a post-transcription regulator, is associated with progression and prognosis. Screening of 152 patients with CML showed that MSI2 was significantly decreased among patients with CML in chronic phase (CP) at diagnosis (p < 0.0001), but found no significant difference between the normal control group and treated patients with CML in CP. Moreover MSI2 was significantly increased (p < 0.0001) in patients with advance disease (AD) CML. Furthermore, our human hematopoietic cell line data imply that MSI2 and BCR-ABL1 mRNA expression are correlated. However, these data cast a doubt on earlier reports that MSI2 effects HES1 expression via NUMB-NOTCH signaling.
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Affiliation(s)
- Jaspal Kaeda
- Charité, Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m.S. Hämatologie und Onkologie , Berlin , Germany
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25
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Talati C, Ontiveros EP, Griffiths EA, Wang ES, Wetzler M. How we will treat chronic myeloid leukemia in 2016. Blood Rev 2014; 29:137-42. [PMID: 25555325 DOI: 10.1016/j.blre.2014.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/17/2014] [Accepted: 12/12/2014] [Indexed: 01/04/2023]
Abstract
Imatinib will become generic in 2016; assuming that its price will decrease precipitously, we expect that the economic forces will change our current practice habits. We reviewed the literature on the current recommendations to treat chronic myeloid leukemia and highlight how we plan to deal with these changes. Specifically, we propose to better characterize patients according to prognostic scores, to allow more attention to those at high risk for disease progression, e.g., 3-month guidelines and BCR/ABL1 message half-time, emphasize compliance by using contemporary technologies, and increase the importance of early monitoring. We hope that our message will open communication between providers, insurance companies and healthcare authorities to offer the best care for our patients.
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Affiliation(s)
- Chetasi Talati
- Internal Medicine, University at Buffalo, Buffalo, NY, USA
| | - Evelena P Ontiveros
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Elizabeth A Griffiths
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Eunice S Wang
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Meir Wetzler
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA.
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26
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Tamari R, Castro-Malaspina H. Transplant for MDS: challenges and emerging strategies. Best Pract Res Clin Haematol 2014; 28:43-54. [PMID: 25659729 DOI: 10.1016/j.beha.2014.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation is the only curative treatment for myelodysplastic syndrome. Major improvements in the field of allogeneic stem cell transplantation have made it a better tolerated treatment that can be offered to older patients and patients with co-morbidities. However, treatment related toxicities, graft versus host disease, infectious complications and relapse remain major problems post transplant. With better understanding of disease biology and prognosis and with different types of conditioning regimens as well as different graft sources, a transplant strategy should be tailored to the individual host to maximize the benefits of this procedure.
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Affiliation(s)
- Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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27
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Shimoni A, Volchek Y, Koren-Michowitz M, Varda-Bloom N, Somech R, Shem-Tov N, Yerushalmi R, Nagler A. Phase 1/2 study of nilotinib prophylaxis after allogeneic stem cell transplantation in patients with advanced chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphoblastic leukemia. Cancer 2014; 121:863-71. [PMID: 25387866 DOI: 10.1002/cncr.29141] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 09/27/2014] [Accepted: 10/01/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allogeneic stem cell transplantation (SCT) remains the standard treatment for advanced chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph(+) ALL). Relapsed disease is the major cause of treatment failure, especially when SCT is given in the setting of advanced disease. Tyrosine kinase inhibitors can be given after transplantation prophylactically or after the detection of minimal residual disease (MRD) to reduce the relapse risk. METHODS Posttransplant nilotinib was started after the achievement of sustained engraftment and the resolution of transplant-related toxicities. Nilotinib was continued until progression or unacceptable toxicity. RESULTS Twenty-two patients with advanced CML (n = 15) or Ph(+) ALL (n = 7) underwent SCT with human leukocyte antigen-matched siblings (n = 11), unrelated donors (n = 7), or alternative donors (n = 4). Sixteen patients were given prophylactic nilotinib maintenance, which was started at a median of 38 days after transplantation. Six patients stopped the treatment because of toxicities (mostly gastrointestinal and hepatic). After nilotinib maintenance, 11 patients achieved (n = 9) or maintained (n = 2) a complete molecular response (CMR), and only 1 of them later relapsed. Four of the 5 patients not achieving CMR relapsed. At a median follow-up of 46 months, 9 patients were alive, and 13 had died. The 2-year overall and progression-free survival rates were 55% (95% confidence interval [CI], 34%-75%) and 45% (95% CI, 25%-66%), respectively. Among the 16 nilotinib recipients, the rates were 69% (95% CI, 46%-92%) and 56% (95% CI, 32%-81%), respectively. The 2-year nonrelapse mortality and relapse rates for all patients were 32% (95% CI, 17%-58%) and 23% (95% CI, 11%-49%), respectively. CONCLUSIONS Nilotinib is relatively safe and effective prophylactic therapy for the prevention of relapse after SCT. It may control MRD and convert patients to CMR, which is associated with prolonged survival. These observations merit further study in larger scale studies.
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Affiliation(s)
- Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel
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28
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Clinical and biological predictors of outcome following relapse of CML post-allo-SCT. Bone Marrow Transplant 2014; 50:189-196. [PMID: 25387087 PMCID: PMC4318796 DOI: 10.1038/bmt.2014.249] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/16/2014] [Accepted: 09/19/2014] [Indexed: 01/27/2023]
Abstract
While there are now fewer allogeneic stem cell transplants (allo-SCT) performed for chronic myeloid leukemia (CML), leukemic relapse post-transplant remains a persistent problem. To better define clinical and biological parameters determining post-relapse outcome, we studied 59 patients with CML relapsing after HLA-identical sibling allo-SCT between 1993 and 2008. Eighteen (30.5%) were transplanted in advanced phase and 41(69.5%) in chronic phase. With a median follow up from relapse of 7.9 years, 5-year post-relapse survival (PRS) was 62%. Multivariate analysis found disease status at transplant, time to diagnosis of relapse from transplant, and pre- transplant TKI use as significant factors associated with PRS. Analysis of BCR-ABL transcript expression in the hematopoietic progenitor compartment was performed in 36 patients (22 relapsed, 8 non-relapsed, and 6 TKI alone controls). Patients with BCR-ABL expression in their early hematopoietic stem cell compartment (HSC: Lineage−CD34+CD38-CD90+) had worse survival irrespective of the disease status. We conclude disease status remains the strongest clinical prognostic factor for PRS in CML following allo-SCT. The persistence of BCR-ABL expression in the progenitor cell compartment in some patients after SCT emphasizes the need to target CML-leukemia stem cells.
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29
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Foo J, Michor F. Evolution of acquired resistance to anti-cancer therapy. J Theor Biol 2014; 355:10-20. [PMID: 24681298 PMCID: PMC4058397 DOI: 10.1016/j.jtbi.2014.02.025] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 12/21/2022]
Abstract
Acquired drug resistance is a major limitation for the successful treatment of cancer. Resistance can emerge due to a variety of reasons including host environmental factors as well as genetic or epigenetic alterations in the cancer cells. Evolutionary theory has contributed to the understanding of the dynamics of resistance mutations in a cancer cell population, the risk of resistance pre-existing before the initiation of therapy, the composition of drug cocktails necessary to prevent the emergence of resistance, and optimum drug administration schedules for patient populations at risk of evolving acquired resistance. Here we review recent advances towards elucidating the evolutionary dynamics of acquired drug resistance and outline how evolutionary thinking can contribute to outstanding questions in the field.
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Affiliation(s)
- Jasmine Foo
- School of Mathematics, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Franziska Michor
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Department of Biostatistics, Harvard School of Public Health, Boston, MA 02215, USA.
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30
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Relapse assessment following allogeneic SCT in patients with MDS and AML. Ann Hematol 2014; 93:1097-110. [PMID: 24671364 DOI: 10.1007/s00277-014-2046-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Options to pre-emptively treat impending relapse of myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) after allogeneic haematopoietic stem cell transplantation (allo-SCT) continuously increase. In recent years, the spectrum of diagnostic methods and parameters to perform post-transplant monitoring in patients with AML and MDS has grown. Cytomorphology, histomorphology, and chimaerism analysis are the mainstay in any panel of post-transplant monitoring. This may be individually combined with multiparameter flow cytometry (MFC) for the detection of residual cells with a leukaemia phenotype and quantitative real-time polymerase chain reaction (RQ-PCR) to assess gene expression, e.g., of WT1 or the residual mutation load (e.g., in case of an NPM1 mutation). Data evaluating the aforementioned methods alone or in combination are discussed in this review with particular emphasis on data pointing towards their suitability to steer pre-emptive post-transplant interventions such as immunotherapy, chemotherapy or therapy with demethylating agents.
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31
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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
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32
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Shanavas M, Messner HA, Kamel-Reid S, Atenafu EG, Gupta V, Kuruvilla J, Kim DDH, Uhm J, Lambie A, Ellis L, Lipton JH. Molecular relapse after allogeneic hematopoietic cell transplant for chronic myeloid leukemia: some long-term survivors appear to tolerate even lack of major molecular response. Leuk Lymphoma 2014; 55:2398-401. [PMID: 24428200 DOI: 10.3109/10428194.2014.882507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mohamed Shanavas
- Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Centre , Toronto , Canada
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33
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Heim D, Gratwohl A. Role of allogeneic transplantation in chronic myeloid leukemia. Expert Rev Hematol 2014; 1:41-50. [DOI: 10.1586/17474086.1.1.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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34
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Imatinib in chronic myeloid leukemia: an overview. Mediterr J Hematol Infect Dis 2014; 6:e2014007. [PMID: 24455116 PMCID: PMC3894842 DOI: 10.4084/mjhid.2014.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 12/02/2013] [Indexed: 12/31/2022] Open
Abstract
Imatinib was the first signal transduction inhibitor (STI), used in a clinical setting. It prevents a BCR-ABL protein from exerting its role in the oncogenic pathway in chronic myeloid leukemia (CML). Imatinib directly inhibits the constitutive tyrosine kinase activity. Imatinib binds to BCR-ABL kinase domain by preventing the transfer of a phosphate group to tyrosine on the protein substrate and the subsequent activation of phosphorylated protein. As the result, the transmission of proliferative signals to the nucleus is blocked and leukemic cell apoptosis is induced. The FDA has approved imatinib as first-line treatment for newly diagnosed CML in December 2002 following an International Randomized Study (IRIS), initiated in June 2000, comparing imatinib at a single daily dose 400 mg to IFN alpha plus cytarabine in newly diagnosed patients with CML in CP. Results from this study show the outstanding effectiveness of imatinib and its superiority with respect to the rates of complete hematological response (CHR), major and complete cytogenetic response (MCyR, CCyR). Patients randomized to imatinib arm at 8 – year data cut off continue to have a durable hematologic and cytogenetic responses, low progression rates to AP or BC, and remarkable survival outcomes. An overall survival (OS) rate is 85% for patients receiving imatinib (93% when only CML-related deaths and those prior to stem cell transplantation are considered). The results have been confirmed in the last years by several groups. According these cumulative results the rates of CCyR achieved after one year of therapy with imatinib at standard dose ranged from 49% to 77%, and the proportion of patients who achieved major molecular response (MMR) after one year ranged between 18% and 58%. Discontinuation of imatinib has been also tried in patients in MMR, a molecular relapse occurs in about one third of patients, generally within 6 months from imatinib cessation.
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35
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Tan Y, Du K, Luo Y, Shi J, Cao L, Zheng Y, Zheng G, Zhao Y, Ye X, Cai Z, Huang H. Superiority of preemptive donor lymphocyte infusion based on minimal residual disease in acute leukemia patients after allogeneic hematopoietic stem cell transplantation. Transfusion 2013; 54:1493-500. [PMID: 24372162 DOI: 10.1111/trf.12524] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/25/2013] [Accepted: 10/01/2013] [Indexed: 12/30/2022]
Affiliation(s)
- Yamin Tan
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Kaili Du
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Yi Luo
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Jimin Shi
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Ling Cao
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Yanlong Zheng
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Gaofeng Zheng
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Xiujing Ye
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - Zhen Cai
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
| | - He Huang
- Bone Marrow Transplantation Center; The First Affiliated Hospital, Zhejiang University School of Medicine; Hangzhou China
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Rousselot P, Charbonnier A, Cony-Makhoul P, Agape P, Nicolini FE, Varet B, Gardembas M, Etienne G, Réa D, Roy L, Escoffre-Barbe M, Guerci-Bresler A, Tulliez M, Prost S, Spentchian M, Cayuela JM, Reiffers J, Chomel JC, Turhan A, Guilhot J, Guilhot F, Mahon FX. Loss of major molecular response as a trigger for restarting tyrosine kinase inhibitor therapy in patients with chronic-phase chronic myelogenous leukemia who have stopped imatinib after durable undetectable disease. J Clin Oncol 2013; 32:424-30. [PMID: 24323036 DOI: 10.1200/jco.2012.48.5797] [Citation(s) in RCA: 304] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE More than half of patients with chronic-phase chronic myelogenous leukemia (CP-CML) in complete molecular response (CMR) experience molecular relapse after imatinib discontinuation. We investigated loss of major molecular response (MMR) as a criterion for resuming therapy. PATIENTS AND METHODS A multicenter observational study (A-STIM [According to Stop Imatinib]) evaluating MMR persistence was conducted in 80 patients with CP-CML who had stopped imatinib after prolonged CMR. RESULTS Median time from imatinib initiation to discontinuation was 79 months (range, 30 to 145 months);median duration of CMR before imatinib discontinuation was 41 months (range, 24 to 96 months); median follow-up after discontinuation was 31 months (range, 8 to 92 months). Twenty-nine patients (36%) lost MMR after a median of 4 months off therapy (range, 2 to 17 months). Cumulative incidence of MMR loss was estimated as 35% (95% CI, 25% to 46%) at 12 months and 36% (95% CI, 26% to 47%) at 24 months, whereas probability of losing CMR was higher. Fluctuation of BCR-ABL transcript levels below the MMR threshold (≥ two consecutive positive values) was observed in 31% of patients after imatinib discontinuation. Treatment-free remission was estimated as 64% (95% CI, 54% to 75%) at 12 and 24 months and 61% (95% CI, 51% to 73%) at 36 months. Median to time to second CMR was estimated as 7.3 months in re-treated patients. CONCLUSION Loss of MMR is a practical and safe criterion for restarting therapy in patients with CML with prolonged CMR.
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Affiliation(s)
- Philippe Rousselot
- Philippe Rousselot, Hôpital Mignot, Université Versailles Saint-Quentin-en-Yvelines, Versailles; Aude Charbonnier, Institut Paoli Calmette, Marseille; Pascale Cony-Makhoul, Hôpital d'Annecy, Pringy; Philippe Agape, Hôpital Felix Guyon-Centre Hospitalier Universitaire en France (CHU) de la Réunion, La Réunion; Franck E. Nicolini, Centre Hospitalier Lyon Sud, Pierre-Bénite; Bruno Varet, Hôpital Necker, Assistance Publique-Hopitaux de Paris (AP-HP) et Université Paris Descartes; Delphine Réa and Jean Michel Cayuela, Hôpital Saint-Louis, AP-HP, Paris; Martine Gardembas, CHU d'Angers, Angers; Gabriel Etienne and Josy Reiffers, Institut Bergonié; François-Xavier Mahon, Hôpital Haut-Levèque et Université Bordeaux Ségalen, Bordeaux; Lydia Roy, Joëlle Guilhot, and François Guilhot, Institut National de la Santé et de la Recherche Médicale (INSERM) Centres d'Investigation Clinique CHU de Poitiers, Poitiers; Martine Escoffre-Barbe, Centre Hospitalier Pontchaillou, Rennes; Agnès Guerci-Bresler, CHU Brabois Vandoeuvre, Nancy; Michel Tulliez, Hôpital Henri Mondor, AP-HP, Créteil; Stéphane Prost, Commissariat à l'Énergie Atomique et aux Énergies Alternatives, Institute of Emerging Diseases and Innovative Therapies, Fontenay-aux-Roses; Marc Spentchian, Hôpital Mignot, Le Chesnay; and Jean Claude Chomel and Ali Turhan, INSERM U935, Université Poitiers et Paris Sud, Le Kremlin Bicêtre, France
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37
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Rein LA, Sung AD, Rizzieri DA. New approaches to manipulate minimal residual disease after allogeneic stem cell transplantation. Int J Hematol Oncol 2013; 2. [PMID: 24303095 DOI: 10.2217/ijh.13.4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Minimal residual disease (MRD) is a complex topic that has been studied extensively in hematologic malignancies given its clinical implications related to prognosis. However, methods to monitor and treat MRD, especially after stem cell transplantation, are not well defined and vary in different disease processes. Alternative transplant strategies, such as reduced-intensity conditioning, have altered the way we assess and address MRD after transplantation. Development of new diagnostic tools have allowed for higher sensitivity and specificity of testing. Both targeted chemotherapeutic agents and immunotherapies have been developed to treat MRD in hopes of improving patient outcomes. This article aims to address ways to define and manipulate MRD specifically after stem cell transplantation.
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Affiliation(s)
- Lindsay Am Rein
- Division of Hematologic Malignancies & Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
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38
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Pavlů J, Apperley JF. Allogeneic stem cell transplantation for chronic myeloid leukemia. Curr Hematol Malig Rep 2013; 8:43-51. [PMID: 23275177 DOI: 10.1007/s11899-012-0149-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In recent years new, more potent tyrosine-kinase inhibitors have been introduced to accompany imatinib for the treatment of chronic myeloid leukemia. Most patients in chronic phase obtain an optimal response to these oral agents with minimal toxicity. Allogeneic stem cell transplantation is therefore indicated only in a minority of patients who do not achieve an adequate response to first, second or third generation agents. Patients in accelerated phase have a lower chance of achieving an optimal response on these drugs. For patients in blast phase, transplantation remains the only therapy with curative potential, although now it is increasingly used in combination with tyrosine-kinase inhibitors. In this review we address the role of allogeneic stem cell transplantation in the treatment of this disease and how patients should be transplanted.
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Affiliation(s)
- Jiří Pavlů
- Imperial College London at Hammersmith Hospital, London, UK.
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39
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Frequency of the ETV6-RUNX1, BCR-ABL1, TCF3-PBX1, and MLL-AFF1 fusion genes in Guatemalan pediatric acute lymphoblastic leukemia patients and their ethnic associations. Cancer Genet 2013; 206:227-32. [PMID: 23859904 DOI: 10.1016/j.cancergen.2013.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 05/21/2013] [Accepted: 05/22/2013] [Indexed: 11/22/2022]
Abstract
Fusion genes involved in acute lymphoblastic leukemia (ALL) occur mostly due to genetic and environmental factors, and only a limited number of studies have reported any ethnic influence. This study assesses whether an ethnic influence has an effect on the frequency of any of the four fusion genes: BCR-ABL1, ETV6-RUNX1, TCF3-PBX1, and MLL-AFF1 found in ALL. To study this ethnic influence, mononuclear cells were obtained from bone marrow samples from 143 patients with ALL. We performed RNA extraction and reverse transcription, then assessed the quality of the cDNA by amplifying the ABL1 control gene, and finally evaluated the presence of the four transcripts by multiplex polymerase chain reaction. We found 10 patients who had the BCR-ABL1 fusion gene (7%); 3 patients (2%) were TCF3-PBX1 positive; and 6 patients (4.5%) were ETV6-RUNX1 positive. The incidence of this last fusion gene is quite low when compared to the values reported in most countries. The low incidence of the ETV6-RUNX1 fusion gene found in Guatemala matches the incidence rates that have been reported in Spain and Indian Romani. Since it is known that an ethnic resemblance exists among these three populations, as shown by ancestral marker studies, the ALL data suggests an ethnic influence on the occurrence and frequency of this particular fusion gene.
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40
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Safety and efficacy of imatinib cessation for CML patients with stable undetectable minimal residual disease: results from the TWISTER study. Blood 2013; 122:515-22. [PMID: 23704092 DOI: 10.1182/blood-2013-02-483750] [Citation(s) in RCA: 541] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Most patients with chronic myeloid leukemia (CML) treated with imatinib will relapse if treatment is withdrawn. We conducted a prospective clinical trial of imatinib withdrawal in 40 chronic-phase CML patients who had sustained undetectable minimal residual disease (UMRD) by conventional quantitative polymerase chain reaction (PCR) on imatinib for at least 2 years. Patients stopped imatinib and were monitored frequently for molecular relapse. At 24 months, the actuarial estimate of stable treatment-free remission was 47.1%. Most relapses occurred within 4 months of stopping imatinib, and no relapses beyond 27 months were seen. In the 21 patients treated with interferon before imatinib, a shorter duration of interferon treatment before imatinib was significantly associated with relapse risk, as was slower achievement of UMRD after switching to imatinib. Highly sensitive patient-specific BCR-ABL DNA PCR showed persistence of the original CML clone in all patients with stable UMRD, even several years after imatinib withdrawal. No patients with molecular relapse after discontinuation have progressed or developed BCR-ABL mutations (median follow-up, 42 months). All patients who relapsed remained sensitive to imatinib re-treatment. These results confirm the safety and efficacy of a trial of imatinib withdrawal in stable UMRD with frequent, sensitive molecular monitoring and early rescue of molecular relapse.
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41
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The significance of BCR-ABL transcripts after allogeneic stem cell transplantation for chronic myeloid leukemia. Biol Blood Marrow Transplant 2013; 19:679-80. [PMID: 23467125 DOI: 10.1016/j.bbmt.2013.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 02/26/2013] [Indexed: 11/23/2022]
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Arpinati M, Tolomelli G, Bochicchio MT, Castagnetti F, Amabile M, Bandini G, Bonifazi F, Stanzani M, Rosti G, Martinelli G, Baccarani M. Molecular monitoring of BCR-ABL transcripts after allogeneic stem cell transplantation for chronic myeloid leukemia. Biol Blood Marrow Transplant 2013; 19:735-40. [PMID: 23333776 DOI: 10.1016/j.bbmt.2013.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 01/11/2013] [Indexed: 01/13/2023]
Abstract
The monitoring of minimal residual disease (MRD) through low sensitivity real-time (RT) polymerase chain reaction (PCR) analysis of BCR-ABL transcripts allows early detection of chronic myeloid leukemia (CML) relapse after allogeneic hematopoietic stem cell transplantation (HSCT). The introduction of more sensitive techniques, such as RT quantitative (Q)-PCR, may lead to an overestimation of the risk of CML relapse. In this study, we reviewed the results of peripheral blood RT Q-PCR in CML patients who underwent allogeneic HSCT from 1983 to 2007. In our laboratory, RT Q-PCR analysis was routinely performed since 2002. Eighty-seven of 189 patients had available RT Q-PCR data; 63 patients had at least 3 RT Q-PCR analyses assessable. Fifty-two of 63 patients (83%) had, at least once, detectable transcript levels, but with an BCR-ABL/ABL ratio <.1% defined as <MR3 (molecular remission <0,1%), whereas 11 (17%) had persistent undetectable BCR-ABL transcripts. Six of 52 patients with <MR3 relapsed, defined as BCR-ABL transcript numbers >.1% confirmed by the finding of Ph+ cells in bone marrow. No patients with persistent undetectable transcripts relapsed (P = .19). Relapse did not correlate with the number of occurrences of <MR3 or with the time to the first <MR3 result. Finally, of 46 patients with detectable transcripts who did not relapse, 35 had undetectable transcripts at last contact. RT Q-PCR analysis had low specificity (19%) and low positive predictive value (12%) in predicting relapse of CML patients after allogeneic HSCT. Our data suggest that detection of low BCR-ABL transcript levels by RT Q-PCR analysis has a poor accuracy in defining the risk of CML relapse and should not be considered as the unique indication to treatment. Fluctuation of BCR-ABL transcripts levels is common as late as ≥10 years posttransplantation, possibly suggesting the long-term persistence of CML stem cells.
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Affiliation(s)
- Mario Arpinati
- Department of Hematology and Oncological Sciences Seragnoli, University of Bologna, Italy.
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Ahmed W, Van Etten RA. Alternative approaches to eradicating the malignant clone in chronic myeloid leukemia: tyrosine-kinase inhibitor combinations and beyond. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:189-200. [PMID: 24319181 PMCID: PMC4529996 DOI: 10.1182/asheducation-2013.1.189] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
In patients with chronic myeloid leukemia (CML) in chronic phase who have achieved complete molecular remission on imatinib therapy, clinical trials from France and Australia have demonstrated that the majority experience prompt molecular relapse of their leukemia upon discontinuation of the drug, showing that long-term monotherapy with tyrosine kinase inhibitors is not curative in the majority of patients with CML. This has focused attention on strategies to eradicate residual disease in CML that is presumed to arise from malignant Ph+ stem cells, which should result in permanent cure and long-term leukemia-free survival. Here, we review the evidence that targeting CML stem cells will be of clinical benefit and discuss pharmacological and immunological approaches to accomplish this goal. Where possible, we link preclinical studies of CML stem cell biology to emerging results from clinical trials of agents that may target these cells.
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MESH Headings
- Australia/epidemiology
- Benzamides/therapeutic use
- Clinical Trials as Topic
- Disease-Free Survival
- France/epidemiology
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Neoplastic Stem Cells/enzymology
- Neoplastic Stem Cells/pathology
- Philadelphia Chromosome
- Piperazines/therapeutic use
- Protein Kinase Inhibitors/therapeutic use
- Pyrimidines/therapeutic use
- Survival Rate
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Affiliation(s)
- Wesam Ahmed
- Division of Hematology/Oncology and Molecular Oncology Research Institute, Tufts Medical Center, Boston, MA
| | - Richard A. Van Etten
- Division of Hematology/Oncology and Molecular Oncology Research Institute, Tufts Medical Center, Boston, MA
- Division of Hematology/Oncology and Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, CA
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Abstract
Abstract
After more than a decade of treatment of chronic myeloid leukemia (CML) patients with the BCR-ABL tyrosine kinase inhibitor imatinib, and despite the impressive clinical results of this targeted therapeutic, many questions remain unresolved. One major question is how to cure CML, and the next step for the future will be to address this key issue. CML is a good model of cancer. The fact that the majority of CML patients who respond very well but discontinue tyrosine kinase inhibitors later show evidence of molecular recurrence focuses attention on the need for further research on leukemic stem cells. The challenge now is to understand why, after stopping treatment, the leukemia recurs in some patients but not in others. If we win this battle, this progress will certainly benefit the treatment and management of other leukemias and solid tumors and will validate this new topic.
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45
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Passé et futur de la LMC: allogreffe de CSH, omacetaxine et ponatinib. ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2217-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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46
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Abstract
Blast crisis (BC) remains the major challenge in the management of chronic myeloid leukemia (CML). It is now generally accepted that BC is the consequence of continued BCR-ABL activity leading to genetic instability, DNA damage, and impaired DNA repair. Most patients with BC carry multiple mutations, and up to 80% show additional chromosomal aberrations in a nonrandom pattern. Treatment with tyrosine kinase inhibitors has improved survival in BC modestly, but most long-term survivors are those who have been transplanted. Patients in BC should be treated with a tyrosine kinase inhibitor according to mutation profile, with or without chemotherapy, with the goal of achieving a second chronic phase and proceeding to allogeneic stem cell transplantation as quickly as possible. Although long-term remissions are rare, allogeneic stem cell transplantation provides the best chance of a cure in BC. Investigational agents are not likely to provide an alternative in the near future. In view of these limited options, prevention of BC by a rigorous and early elimination of BCR-ABL is recommended. Early response indicators should be used to select patients for alternative therapies and early transplantation. Every attempt should be made to reduce or eliminate BCR-ABL consistent with good patient care as far as possible.
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47
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Chronic myelogenous leukemia: role of stem cell transplant in the imatinib era. Hematol Oncol Clin North Am 2012; 25:1025-48, vi. [PMID: 22054733 DOI: 10.1016/j.hoc.2011.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the pre-tyrosine kinase (TKI) era, allogeneic stem cell transplant (allo-SCT) was the front-line treatment of choice for young patients with chronic myelogenous leukemia (CML). Today, imatinib is well established as front-line therapy for CML, with excellent long-term outcomes. This has changed the role of allo-SCT and the number of patients undergoing allo-SCT has declined dramatically. Allo-SCT is currently recommended for patients in accelerated/blast phase disease, those who have failed a second-generation TKI and those with TKI-resistant mutations such as T315I. The role of allo-SCT in the management of CML will require continual reappraisal as medical therapies continue to evolve.
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48
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Tang M, Foo J, Gönen M, Guilhot J, Mahon FX, Michor F. Selection pressure exerted by imatinib therapy leads to disparate outcomes of imatinib discontinuation trials. Haematologica 2012; 97:1553-61. [PMID: 22419579 DOI: 10.3324/haematol.2012.062844] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Chronic myeloid leukemia is successfully managed by imatinib therapy, but the question remains whether treatment must be administered indefinitely. Imatinib discontinuation trials have led to two distinct outcomes: about 60% of patients experienced disease relapse within 6 months of treatment cessation, while the remaining 40% remained disease-free throughout the duration of follow-up. We aimed to investigate the mechanisms underlying these disparate clinical outcomes. DESIGN AND METHODS We utilized molecular data from the "Stop Imatinib" trial together with a mathematical framework of chronic myeloid leukemia, based on a four-compartment model that can explain the kinetics of the molecular response to imatinib. This approach was complemented by statistical analyses to estimate system parameters and investigate whether chronic myeloid leukemia can be cured by imatinib therapy alone. RESULTS We found that there are insufficient follow-up data from the "Stop Imatinib" trial in order to conclude whether the absence of a relapse signifies cure of the disease. We determined that selection of less aggressive leukemic phenotypes by imatinib therapy recapitulates the trial outcomes. This postulated mechanism agrees with the observation that most patients who have a complete molecular response after discontinuation of imatinib continue to harbor minimal residual disease, and might work in concert with other factors suppressing leukemic cell expansion when the tumor burden remains low. CONCLUSIONS Our analysis provides evidence for a mechanistic model of chronic myeloid leukemia selection by imatinib treatment and suggests that it may not be safe to discontinue therapy outside a clinical trial.
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Affiliation(s)
- Min Tang
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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Rea D, Rousselot P, Guilhot J, Guilhot F, Mahon FX. Curing Chronic Myeloid Leukemia. Curr Hematol Malig Rep 2012; 7:103-8. [DOI: 10.1007/s11899-012-0117-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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50
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Bacher U, Talano JA, Bishop MR. Monitoring and Prevention of Relapse after Allogeneic Hematopoietic Cell Transplantation for Myeloid Malignancies. Biol Blood Marrow Transplant 2012; 18:S62-73. [DOI: 10.1016/j.bbmt.2011.10.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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