1
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Webster JA, Robinson TM, Blackford AL, Warlick E, Ferguson A, Borrello I, Zahurak M, Jones RJ, Smith BD. A randomized, phase II trial of adjuvant immunotherapy with durable TKI-free survival in patients with chronic phase CML. Leuk Res 2021; 111:106737. [PMID: 34768161 DOI: 10.1016/j.leukres.2021.106737] [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: 06/01/2021] [Revised: 10/14/2021] [Accepted: 10/25/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Chronic myeloid leukemia (CP-CML) patients can achieve undetectable minimal residual disease (UMRD) and discontinue tyrosine kinase inhibitors (TKIs). Cellular immunity plays an important role in CML disease control. We conducted a randomized, non-blinded phase II trial of adjuvant immunotherapy with TKIs to facilitate TKI discontinuation. METHODS TKI-treated patients with CP-CML were randomized to receive the K562/GM-CSF vaccine (vaccine) OR Interferon-α + Sargramostim (IFN). If UMRD was achieved, then all treatment was stopped. Patients who did not achieve UMRD within one year, had a molecular relapse, or discontinued therapy for toxicity could crossover. RESULTS Thirty-four patients were randomized to IFN (n = 18) or vaccine (n = 16), and 21 patients crossed over (IFN⟶vaccine: n = 9, vaccine⟶IFN, n = 12). TKIs at enrollment included imatinib (n = 31), nilotinib (n = 2), and dasatinib (n = 1). No patients discontinued vaccine due to side effects, while 33 % of IFN-treated patients discontinued treatment. More patients randomized to IFN (47.4 %, 95 % CI: 16.7-66.7 %) versus vaccine (25.0 %, 95 % CI: 0.5-43.5 %) achieved UMRD within one year. Seven patients randomized to IFN discontinued treatment with 28.6 % (95 % CI: 8.9-92.2 %) sustaining treatment-free remission (TFR) at 1 year, while three patients randomized to vaccine discontinued treatment with none sustaining TFR. Including crossover, there was a cumulative discontinuation success rate of 36.4 % (95 % CI: 16.6 %-79.5 %) after adjuvant IFN. Patients who sustained TFR received a median of 29 months of imatinib prior to discontinuation. CONCLUSION Adjuvant IFN led to durable TFRs with limited prior TKI exposure with comparable success to prior discontinuation trials, but many patients stopped IFN early.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of MedIcine, Baltimore, MD, United States.
| | | | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Erica Warlick
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Anna Ferguson
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of MedIcine, Baltimore, MD, United States
| | - Ivan Borrello
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of MedIcine, Baltimore, MD, United States
| | - Marianna Zahurak
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Richard J Jones
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of MedIcine, Baltimore, MD, United States
| | - B Douglas Smith
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of MedIcine, Baltimore, MD, United States
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2
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Gutiérrez LG, Abelleyro MM, Ruiz MS, Anchordoqui MS, Freitas J, Bianchini M, De Brasi CD, Larripa IB. Development of an inverse-PCR approach for characterization of the major BCR-ABL1 breakpoint sequences on genomic DNA: proof of concept. Clin Chem Lab Med 2021; 59:e449-e453. [PMID: 34162038 DOI: 10.1515/cclm-2020-1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Leandro G Gutiérrez
- Instituto de Medicina Experimental (IMEX), CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Miguel M Abelleyro
- Instituto de Medicina Experimental (IMEX), CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina
| | - María Sol Ruiz
- Centro de Investigaciones Oncológicas-Fundación Cáncer (CIO-FUCA), Buenos Aires, Argentina
| | | | - Josefina Freitas
- Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | - Michele Bianchini
- Centro de Investigaciones Oncológicas-Fundación Cáncer (CIO-FUCA), Buenos Aires, Argentina
| | - Carlos D De Brasi
- Instituto de Medicina Experimental (IMEX), CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina.,Instituto de Investigaciones Hematológicas (IIHEMA), Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Irene B Larripa
- Instituto de Medicina Experimental (IMEX), CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina
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3
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Mu H, Zhu X, Jia H, Zhou L, Liu H. Combination Therapies in Chronic Myeloid Leukemia for Potential Treatment-Free Remission: Focus on Leukemia Stem Cells and Immune Modulation. Front Oncol 2021; 11:643382. [PMID: 34055612 PMCID: PMC8155539 DOI: 10.3389/fonc.2021.643382] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/21/2021] [Indexed: 12/18/2022] Open
Abstract
Although tyrosine Kinase Inhibitors (TKI) has revolutionized the treatment of chronic myeloid leukemia (CML), patients are not cured with the current therapy modalities. Also, the more recent goal of CML treatment is to induce successful treatment-free remission (TFR) among patients achieving durable deep molecular response (DMR). Together, it is necessary to develop novel, curative treatment strategies. With advancements in understanding the biology of CML, such as dormant Leukemic Stem Cells (LSCs) and impaired immune modulation, a number of agents are now under investigation. This review updates such agents that target LSCs, and together with TKIs, have the potential to eradicate CML. Moreover, we describe the developing immunotherapy for controlling CML.
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Affiliation(s)
- Hui Mu
- Medical School, Nantong University, Nantong, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Jia
- Medical School, Nantong University, Nantong, China
| | - Lu Zhou
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hong Liu
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, China
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4
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Branford S. Why is it critical to achieve a deep molecular response in chronic myeloid leukemia? Haematologica 2020; 105:2730-2737. [PMID: 33054104 PMCID: PMC7716360 DOI: 10.3324/haematol.2019.240739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The primary goal of tyrosine kinase inhibitor (TKI) therapy for patients with chronic myeloid leukemia is survival, which is achieved by the vast majority of patients. The initial response to therapy provides a sensitive measure of future clinical outcome. Measurement of BCR-ABL1 transcript levels using real-time quantitative polymerase chain reaction standardized to the international reporting scale is now the principal recommended monitoring strategy. The method is used to assess early milestone responses and provides a guide for therapeutic intervention. When patients successfully traverse the critical first 12 months of TKI therapy, most will head towards another milestone response, deep molecular response (DMR, BCR-ABL1 ≤0.01%). DMR is essential for patients aiming to achieve treatment-free remission and a prerequisite for a trial of TKI discontinuation. The success of discontinuation trials has led to new treatment strategies in order for more patients to reach this milestone response. DMR has been incorporated into endpoints of clinical trials and is considered by some expert groups as the optimal treatment response. But is DMR a stable response and does it provide the ultimate protection against TKI resistance and death? Do we need to increase the sensitivity of detection of BCR-ABL1 to better identify the patients who would likely remain in treatment-free remission after TKI discontinuation? Is it necessary to switch current TKI therapy to a more potent inhibitor if the goal is to achieve DMR? These are issues that I will explore in this review.
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Affiliation(s)
- Susan Branford
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology; School of Pharmacy and Medical Science, Division of Health Sciences, University of South Australia; School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide and School of Biological Sciences, University of Adelaide, Adelaide.
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5
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Warda W, Larosa F, Neto Da Rocha M, Trad R, Deconinck E, Fajloun Z, Faure C, Caillot D, Moldovan M, Valmary-Degano S, Biichle S, Daguindau E, Garnache-Ottou F, Tabruyn S, Adotevi O, Deschamps M, Ferrand C. CML Hematopoietic Stem Cells Expressing IL1RAP Can Be Targeted by Chimeric Antigen Receptor-Engineered T Cells. Cancer Res 2018; 79:663-675. [PMID: 30514753 DOI: 10.1158/0008-5472.can-18-1078] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/09/2018] [Accepted: 11/29/2018] [Indexed: 12/16/2022]
Abstract
Chronic myeloid leukemia (CML) is a chronic disease resulting in myeloid cell expansion through expression of the BCR-ABL1 fusion transcript. Tyrosine kinase inhibitors (TKI) have significantly increased survival of patients with CML, and deep responders may consider stopping the treatment. However, more than 50% of patients relapse and restart TKI, subsequently suffering unknown toxicity. Because CML is a model immune system-sensitive disease, we hypothesize that chimeric antigen receptor (CAR) T cells targeting IL1 receptor-associated protein (IL1RAP) in quiescent CML stem cells may offer an opportunity for a permanent cure. In this study, we produced and molecularly characterized a specific monoclonal anti-IL1RAP antibody from which fragment antigen-binding nucleotide coding sequences were cloned as a single chain into a lentiviral backbone and secured with the suicide gene iCASP9/rimiducid system. Our CAR T-cell therapy exhibited cytotoxicity against both leukemic stem cells and, to a lesser extent, monocytes expressing IL1RAP, with no apparent effect on the hematopoietic system, including CD34+ stem cells. This suggests IL1RAP as a tumor-associated antigen for immunotherapy cell targeting. IL1RAP CAR T cells were activated in the presence of IL1RAP+ cell lines or primary CML cells, resulting in secretion of proinflammatory cytokines and specifically killing in vitro and in a xenograft murine model. Overall, we demonstrate the proof of concept of a CAR T-cell immunotherapy approach in the context of CML that is applicable for young patients and primary TKI-resistant, intolerant, or allograft candidate patients. SIGNIFICANCE: These findings present the first characterization and proof of concept of a chimeric antigen receptor directed against IL1RAP expressed by leukemic stem cells in the context of CML.
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Affiliation(s)
- Walid Warda
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France.,Laboratory of Applied Biotechnology, Azm Centre for Research in Biotechnology and its Applications, EDST and Faculty of Sciences 3, Lebanese University, Tripoli, Liban
| | - Fabrice Larosa
- Department of Hematology, University Hospital of Besancon, Besancon, France
| | | | - Rim Trad
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France
| | - Eric Deconinck
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France.,Department of Hematology, University Hospital of Besancon, Besancon, France
| | - Ziad Fajloun
- Laboratory of Applied Biotechnology, Azm Centre for Research in Biotechnology and its Applications, EDST and Faculty of Sciences 3, Lebanese University, Tripoli, Liban
| | - Cyril Faure
- Department of Internal Medicine, Hospital of Haute Saone, Vesoul, France
| | - Denis Caillot
- Department of Hematology, University Hospital of Dijon, Dijon, France
| | - Marius Moldovan
- Department of Internal Medicine, Hospital Nord Franche-Comté, Belfort, France
| | | | - Sabeha Biichle
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France
| | - Etienne Daguindau
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France.,Department of Hematology, University Hospital of Besancon, Besancon, France
| | | | | | - Olivier Adotevi
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France
| | - Marina Deschamps
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France
| | - Christophe Ferrand
- INSERM UMR1098, EFS BFC, University of Bourgogne Franche-Comté, Besançon, France.
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6
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Evaluation of the primitive fraction by functional in vitro assays at the RNA and DNA level represents a novel tool for complementing molecular monitoring in chronic myeloid leukemia. Oncotarget 2018; 9:20255-20264. [PMID: 29755649 PMCID: PMC5945542 DOI: 10.18632/oncotarget.24749] [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: 09/01/2017] [Accepted: 03/06/2018] [Indexed: 11/30/2022] Open
Abstract
Quantification of BCR-ABL1 mRNA levels in peripheral blood of chronic myeloid leukemia patients is a strong indicator of response to tyrosine-kinase inhibitors (TKI) treatment. However, additional prognostic markers are needed in order to better classify patients. The hypothesis of leukemic stem cells (LSCs) heterogeneity and persistence, suggests that their functional evaluation could be of clinical interest. In this work, we assessed the primitive and progenitor fractions in patients at diagnosis and during TKI treatment using functional in vitro assays, defining a “functional leukemic burden” (FLB). We observed that the FLB was reduced in vivo in both fractions upon treatment. However, different FLB levels were observed among patients according to their response to treatment, suggesting that quantification of the FLB could complement early molecular monitoring. Given that FLB assessment is limited by BCR-ABL1 mRNA expression levels, we developed a novel detection method of primitive cells at the DNA level, using patient-specific primers and direct nested PCR in colonies obtained from functional in vitro assays. We believe that this method could be useful in the context of discontinuation trials, given that it is unknown whether the persistent leukemic clone represents LSCs, able to resume the leukemia upon TKI removal.
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7
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Rainero A, Angaroni F, D'Avila F, Conti A, Pirrone C, Micheloni G, Tararà L, Millefanti G, Maserati E, Valli R, Spinelli O, Buklijas K, Michelato A, Casalone R, Barlassina C, Barcella M, Sirchia S, Piscitelli E, Caccia M, Porta G. gDNA qPCR is statistically more reliable than mRNA analysis in detecting leukemic cells to monitor CML. Cell Death Dis 2018; 9:349. [PMID: 29500381 PMCID: PMC5834620 DOI: 10.1038/s41419-018-0387-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
Chronic Myeloid Leukemia (CML) is a stem cell cancer that arises when t(9;22) translocation occurs in a hematopoietic stem cells. This event results in the expression of the BCR-ABL1 fusion gene, which codes for a constitutively active tyrosine kinase that is responsible for the transformation of a HSC into a CML stem cell, which then gives rise to a clonal myeloproliferative disease. The introduction of Tyrosine Kinase Inhibitors (TKIs) has revolutionized the management of the disease. However, these drugs do not seem to be able to eradicate the malignancy. Indeed, discontinuation trials (STIM; TWISER; DADI) for those patients who achieved a profound molecular response showed 50% relapsing within 12 months. We performed a comparative analysis on 15 CML patients and one B-ALL patient, between the standard quantitative reverse-transcriptase PCR (qRT-PCR) and our genomic DNA patient-specific quantitative PCR assay (gDNA qPCR). Here we demonstrate that gDNA qPCR is better than standard qRT-PCR in disease monitoring after an average follow-up period of 200 days. Specifically, we statistically demonstrated that DNA negativity is more reliable than RNA negativity in indicating when TKIs therapy can be safely stopped.
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Affiliation(s)
- Alessia Rainero
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - Fabrizio Angaroni
- Department of Science and High Technology, University of Insubria, Como, Italy
- IFN (National Institute of Nuclear Physics), Como, Italy
| | - Francesca D'Avila
- Immunology and Functional Genomics Unit, Centro Cardiologico Monzino IRCCS, via Parea 4, 20138, Milan, Italy
| | - Andrea Conti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cristina Pirrone
- Department of Biology and Life Sciences, University of Insubria, Varese, Italy
| | - Giovanni Micheloni
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lucia Tararà
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Giorgia Millefanti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Emanuela Maserati
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Roberto Valli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Orietta Spinelli
- Department of Hematology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ksenija Buklijas
- Department of Hematology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Michelato
- Department of Hematology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Rosario Casalone
- Department of Genetics and Cytogenetics, ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | | | - Matteo Barcella
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Silvia Sirchia
- Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Massimo Caccia
- Department of Science and High Technology, University of Insubria, Como, Italy
| | - Giovanni Porta
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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8
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Chomel JC, Bonnet ML, Sorel N, Sloma I, Bennaceur-Griscelli A, Rea D, Legros L, Marfaing-Koka A, Bourhis JH, Ame S, Guerci-Bresler A, Rousselot P, Turhan AG. Leukemic stem cell persistence in chronic myeloid leukemia patients in deep molecular response induced by tyrosine kinase inhibitors and the impact of therapy discontinuation. Oncotarget 2018; 7:35293-301. [PMID: 27167108 PMCID: PMC5085229 DOI: 10.18632/oncotarget.9182] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/10/2016] [Indexed: 11/25/2022] Open
Abstract
During the last decade, the use of tyrosine kinase inhibitor (TKI) therapy has modified the natural history of chronic myeloid leukemia (CML) allowing an increase of the overall and disease-free survival, especially in patients in whom molecular residual disease becomes undetectable. However, it has been demonstrated that BCR-ABL1- expressing leukemic stem cells (LSCs) persist in patients in deep molecular response. It has also been shown that the discontinuation of Imatinib leads to a molecular relapse in the majority of cases. To determine a possible relationship between these two phenomena, we have evaluated by clonogenic and long-term culture initiating cell (LTC-IC) assays, the presence of BCR-ABL1-expressing LSCs in marrow samples from 21 patients in deep molecular response for three years after TKI therapy (mean duration seven years). LSCs were detected in 4/21 patients. Discontinuation of TKI therapy in 13/21 patients led to a rapid molecular relapse in five patients (4 without detectable LSCs and one with detectable LSCs). No relapse occurred in the eight patients still on TKI therapy, whether LSCs were detectable or not. Thus, this study demonstrates for the first time the in vivo efficiency of TKIs, both in the progenitor and the LSC compartments. It also confirms the persistence of leukemic stem cells in patients in deep molecular response, certainly at the origin of relapses. Finally, it emphasizes the difficulty of detecting residual LSCs due to their rarity and their low BCR-ABL1 mRNA expression.
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Affiliation(s)
- Jean Claude Chomel
- Laboratoire de Cancérologie Biologique, CHU de Poitiers, Poitiers, France.,INSERM U935, Poitiers, France
| | | | - Nathalie Sorel
- Laboratoire de Cancérologie Biologique, CHU de Poitiers, Poitiers, France.,INSERM U935, Poitiers, France
| | - Ivan Sloma
- Service d'Hématologie Biologique, Hôpital Paul Brousse, Villejuif, France.,INSERM U935, Villejuif, France.,Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Annelise Bennaceur-Griscelli
- Service d'Hématologie Biologique, Hôpital Paul Brousse, Villejuif, France.,INSERM U935, Villejuif, France.,Université Paris Sud, Le Kremlin-Bicêtre, France
| | - Delphine Rea
- Service d'Hématologie Adulte, Hôpital Saint Louis, Paris, France.,INSERM UMRS-1160, IUH-Université Paris Diderot-Paris 7, Paris, France
| | - Laurence Legros
- Service d'Hématologie Clinique, Hôpital l'Archet, Nice, France
| | - Anne Marfaing-Koka
- Service d'Hématologie Biologique, Hôpital Antoine Béclère, Clamart, France
| | - Jean-Henri Bourhis
- Service d'Hématologie Biologique, Hôpital Antoine Béclère, Clamart, France.,Service d'Hématologie-Greffe de Moelle, Institut Gustave Roussy, Villejuif, France
| | - Shanti Ame
- Département d'Hématologie et Oncologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Philippe Rousselot
- Service d'Hématologie et Oncologie, Centre Hospitalier de Versailles, Versailles, France.,EA4340, Université Versailles-Saint Quentin en Yvelines, Université Paris-Saclay, France
| | - Ali G Turhan
- INSERM U935, Poitiers, France.,Service d'Hématologie Biologique, Hôpital Paul Brousse, Villejuif, France.,INSERM U935, Villejuif, France.,Université Paris Sud, Le Kremlin-Bicêtre, France.,Service d'Hématologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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9
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Monitoring of childhood ALL using BCR-ABL1 genomic breakpoints identifies a subgroup with CML-like biology. Blood 2017; 129:2771-2781. [PMID: 28331056 DOI: 10.1182/blood-2016-11-749978] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/17/2017] [Indexed: 12/20/2022] Open
Abstract
We used the genomic breakpoint between BCR and ABL1 genes for the DNA-based monitoring of minimal residual disease (MRD) in 48 patients with childhood acute lymphoblastic leukemia (ALL). Comparing the results with standard MRD monitoring based on immunoglobulin/T-cell receptor (Ig/TCR) gene rearrangements and with quantification of IKZF1 deletion, we observed very good correlation for the methods in a majority of patients; however, >20% of children (25% [8/32] with minor and 12.5% [1/8] with major-BCR-ABL1 variants in the consecutive cohorts) had significantly (>1 log) higher levels of BCR-ABL1 fusion than Ig/TCR rearrangements and/or IKZF1 deletion. We performed cell sorting of the diagnostic material and assessed the frequency of BCR-ABL1-positive cells in various hematopoietic subpopulations; 12% to 83% of non-ALL B lymphocytes, T cells, and/or myeloid cells harbored the BCR-ABL1 fusion in patients with discrepant MRD results. The multilineage involvement of the BCR-ABL1-positive clone demonstrates that in some patients diagnosed with BCR-ABL1-positive ALL, a multipotent hematopoietic progenitor is affected by the BCR-ABL1 fusion. These patients have BCR-ABL1-positive clonal hematopoiesis resembling a chronic myeloid leukemia (CML)-like disease manifesting in "lymphoid blast crisis." The biological heterogeneity of BCR-ABL1-positive ALL may impact the patient outcomes and optimal treatment (early stem cell transplantation vs long-term administration of tyrosine-kinase inhibitors) as well as on MRD testing. Therefore, we recommend further investigations on CML-like BCR-ABL1-positive ALL.
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10
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Alikian M, Gale RP, Apperley JF, Foroni L. Molecular techniques for the personalised management of patients with chronic myeloid leukaemia. BIOMOLECULAR DETECTION AND QUANTIFICATION 2017; 11:4-20. [PMID: 28331814 PMCID: PMC5348117 DOI: 10.1016/j.bdq.2017.01.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 12/28/2016] [Accepted: 01/18/2017] [Indexed: 12/25/2022]
Abstract
Chronic myeloid leukemia (CML) is the paradigm for targeted cancer therapy. RT-qPCR is the gold standard for monitoring response to tyrosine kinase-inhibitor (TKI) therapy based on the reduction of blood or bone marrow BCR-ABL1. Some patients with CML and very low or undetectable levels of BCR-ABL1 transcripts can stop TKI-therapy without CML recurrence. However, about 60 percent of patients discontinuing TKI-therapy have rapid leukaemia recurrence. This has increased the need for more sensitive and specific techniques to measure residual CML cells. The clinical challenge is to determine when it is safe to stop TKI-therapy. In this review we describe and critically evaluate the current state of CML clinical management, different technologies used to monitor measurable residual disease (MRD) focus on comparingRT-qPCR and new methods entering clinical practice. We discuss advantages and disadvantages of new methods.
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Key Words
- ABL1, Abelson murine leukaemia virus
- ALL, acute lymphoblastic leukaemia
- AP, accelerated phase
- ARQ, armored RNA Quant
- ATP, adenosine triphosphate
- BC, blast crisis
- BCR, breakpoint cluster region
- BM, bone marrow
- BMT, bone marrow transplantation
- Bp, base pair
- CAP, College of American Pathology
- CES, capillary electrophoresis sequencing
- CML
- CML, chronic myeloid leukaemia
- CMR, complete molecular response/remission
- CP, chronic phase
- DESTINY, De-Escalation and Stopping Treatment of Imatinib, Nilotinib or sprYcel in Chronic Myeloid Leukaemia
- DNA, deoxyribonucleic acid
- EAC, Europe Against Cancer
- ELN, European Leukaemia Net
- EURO-SKI, European Stop Tyrosine Kinase Inhibitor Study
- GUSB, glucuronidase beta gene
- IC, inhibotory concentration
- IRIS, interferon and cytarabine versus STI571
- IS, International Scale
- InDels, insertions and deletions
- KDa, Kilo Dalton
- Kbp, Kilo Base Pairs
- LPC, leukemic progenitor cells
- LSC, leukemic stem cell
- LoD, limit of detection
- LoQ, limit of quantification
- M-bcr, major-breakpoint cluster region
- MMR, major molecular response/remission
- MR, deep molecular response/remission
- MRD
- MRD, minimal residual disease
- Mbp, mega base pair
- Molecular monitoring
- NCCN, National Comprehensive Cancer Network
- NEQAS, National External Quality Assessement Service
- NGS
- NGS, next generation sequencing
- NTC, No Template Control
- PB, Peripheral Blood
- PCR, Polymerase Chain Reaction
- PFS, Progression Free Survival
- Ph, Philadelpia
- Q-PCR, quantitative polymerase chain reaction
- QC, Quality Control
- RT, reverse transcription
- RT-dPCR, reverse transcription-digital polymerase chain reaction
- RT-qPCR, reverse transcription-quantitative polymerase chain reaction
- SCT, stem cell transplant
- SMRT, single-molecule real-time sequencing
- STIM, stop imatinib
- TKD, tyrosine kinase domain
- TKI, tyrosine kinase inhibitor
- WHO, World Health Organisation
- ZMW, zero-mode wave-guided
- allo-SCT, Allogeneic Stem Cell Transplantation
- cDNA, coding or complimentary DNA
- dMIQE, Minimum Information for Publication of Quantitative Digital PCR Experiments
- dPCR
- dPCR, digital polymerase chain reaction
- emPCR, emulsion PCR
- gDNA, genomic deoxyribonucleic acid
- m-bcr, minor-breakpoint cluster region
- mRNA, messenger RNA
- nM, manomolar
- μ-bcr, micro-breakpoint cluster region
- μg, microgram
- μl, microliter
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Affiliation(s)
- Mary Alikian
- Centre for Haematology, Department of Medicine, Imperial College London Hammersmith Hospital, London UK; Imperial Molecular Pathology, Imperial College Healthcare Trust, Hammersmith Hospital, London, UK
| | - Robert Peter Gale
- Centre for Haematology, Department of Medicine, Imperial College London Hammersmith Hospital, London UK
| | - Jane F Apperley
- Centre for Haematology, Department of Medicine, Imperial College London Hammersmith Hospital, London UK
| | - Letizia Foroni
- Centre for Haematology, Department of Medicine, Imperial College London Hammersmith Hospital, London UK
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11
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Necrotizing Liver Granuloma/Abscess and Constrictive Aspergillosis Pericarditis with Central Nervous System Involvement: Different Remarkable Phenotypes in Different Chronic Granulomatous Disease Genotypes. Case Reports Immunol 2017; 2017:2676403. [PMID: 28168067 PMCID: PMC5259602 DOI: 10.1155/2017/2676403] [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: 11/01/2016] [Accepted: 12/21/2016] [Indexed: 11/17/2022] Open
Abstract
Chronic granulomatous disease (CGD) is a primary immune deficiency causing predisposition to infections with specific microorganisms, Aspergillus species and Staphylococcus aureus being the most common ones. A 16-year-old boy with a mutation in CYBB gene coding gp91phox protein (X-linked disease) developed a liver abscess due to Staphylococcus aureus. In addition to medical therapy, surgical treatment was necessary for the management of the disease. A 30-month-old girl with an autosomal recessive form of chronic granulomatous disease (CYBA gene mutation affecting p22phox protein) had invasive aspergillosis causing pericarditis, pulmonary abscess, and central nervous system involvement. The devastating course of disease regardless of the mutation emphasizes the importance of early diagnosis and intervention of hematopoietic stem cell transplantation as soon as possible in children with CGD.
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12
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Marum JE, Branford S. Current developments in molecular monitoring in chronic myeloid leukemia. Ther Adv Hematol 2016; 7:237-251. [PMID: 27695615 PMCID: PMC5026293 DOI: 10.1177/2040620716657994] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Molecular monitoring plays an essential role in the clinical management of chronic myeloid leukemia (CML) patients, and now guides clinical decision making. Quantitative reverse-transcriptase-polymerase-chain-reaction (qRT-PCR) assessment of BCR-ABL1 transcript levels has become the standard of care protocol in CML. However, further developments are required to assess leukemic burden more efficiently, monitor minimal residual disease (MRD), detect mutations that drive resistance to tyrosine kinase inhibitor (TKI) therapy and identify predictors of response to TKI therapy. Cartridge-based BCR-ABL1 quantitation, digital PCR and next generation sequencing are examples of technologies which are currently being explored, evaluated and translated into the clinic. Here we review the emerging molecular methods/technologies currently being developed to advance molecular monitoring in CML.
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Affiliation(s)
- Justine Ellen Marum
- Centre for Cancer Biology, SA Pathology, Adelaide, Australia
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Susan Branford
- Centre for Cancer Biology, SA Pathology, Adelaide, Australia
- School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
- School of Medicine, University of Adelaide, SA, Adelaide, Australia
- School of Biological Sciences, University of Adelaide, Adelaide, SA, Australia
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13
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Soverini S, De Benedittis C, Mancini M, Martinelli G. Present and future of molecular monitoring in chronic myeloid leukaemia. Br J Haematol 2016; 173:337-49. [PMID: 26947577 DOI: 10.1111/bjh.13966] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Currently, physicians treating chronic myeloid leukaemia (CML) patients can rely on a wide spectrum of therapeutic options: the best use of such options is essential to achieve excellent clinical outcomes and, possibly, treatment-free remission (TFR). To accomplish this, proper integration of expert clinical and laboratory monitoring of CML patients is fundamental. Molecular response (MR) monitoring of patients at defined time points has emerged as an important success factor for optimal disease management and BCR-ABL1 kinase domain mutation screening is useful to guide therapeutic reassessment in patients who do not achieve optimal responses to tyrosine kinase inhibitor therapy. Deeper MRs might be associated with improved long-term survival outcomes. More importantly, they are considered a gateway to TFR. In molecular biology, novel procedures and technologies are continually being developed. More sophisticated molecular tools and automated analytical solutions are emerging as CML treatment endpoints and expectations become more and more ambitious. Here we provide a critical overview of current and novel methodologies, present their strengths and pitfalls and discuss what their present and future role might be.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Caterina De Benedittis
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
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14
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Alikian M, Ellery P, Forbes M, Gerrard G, Kasperaviciute D, Sosinsky A, Mueller M, Whale AS, Milojkovic D, Apperley J, Huggett JF, Foroni L, Reid AG. Next-Generation Sequencing-Assisted DNA-Based Digital PCR for a Personalized Approach to the Detection and Quantification of Residual Disease in Chronic Myeloid Leukemia Patients. J Mol Diagn 2016; 18:176-89. [PMID: 26857065 DOI: 10.1016/j.jmoldx.2015.09.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 08/31/2015] [Accepted: 09/17/2015] [Indexed: 01/06/2023] Open
Abstract
Recent studies indicate that 40% of chronic myeloid leukemia patients who achieve sustained undetectable BCR-ABL1 transcripts on tyrosine kinase inhibitor therapy remain disease-free after drug discontinuation. In contrast, 60% experience return of detectable disease and have to restart treatment, thus highlighting the need for an improved method of identifying patients with the lowest likelihood of relapse. Here we describe the validation of a personalized DNA-based digital PCR (dPCR) approach for quantifying very low levels of residual disease, which involves the rapid identification of t(9;22) fusion junctions using targeted next-generation sequencing coupled with the use of a dPCR platform. t(9;22) genomic breakpoints were successfully mapped in samples from 32 of 32 patients with early stage disease. Disease quantification by DNA-based dPCR was performed using the Fluidigm BioMark platform on 46 follow-up samples from 6 of the 32 patients, including 36 samples that were in deep molecular remission. dPCR detected persistent disease in 81% of molecular-remission samples, outperforming both RT-dPCR (25%) and DNA-based quantitative PCR (19%). We conclude that dPCR for BCR-ABL1 DNA is the most sensitive available method of residual-disease detection in chronic myeloid leukemia and may prove useful in the management of tyrosine kinase inhibitor withdrawal.
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Affiliation(s)
- Mary Alikian
- Imperial Molecular Pathology, Imperial Healthcare Trust, Hammersmith Hospital, London, United Kingdom; Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom.
| | - Peter Ellery
- Imperial Molecular Pathology, Imperial Healthcare Trust, Hammersmith Hospital, London, United Kingdom
| | - Martin Forbes
- Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gareth Gerrard
- Imperial Molecular Pathology, Imperial Healthcare Trust, Hammersmith Hospital, London, United Kingdom; Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dalia Kasperaviciute
- Clinical Genome Informatics Facility, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Alona Sosinsky
- Clinical Genome Informatics Facility, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Michael Mueller
- Clinical Genome Informatics Facility, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Alexandra S Whale
- Molecular & Cell Biology, LGC Limited, Queens Road, Teddington, United Kingdom
| | - Dragana Milojkovic
- Clinical Haematology, Imperial College Healthcare National Health Institute Trust, London, United Kingdom
| | - Jane Apperley
- Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jim F Huggett
- Molecular & Cell Biology, LGC Limited, Queens Road, Teddington, United Kingdom
| | - Letizia Foroni
- Imperial Molecular Pathology, Imperial Healthcare Trust, Hammersmith Hospital, London, United Kingdom; Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Alistair G Reid
- Imperial Molecular Pathology, Imperial Healthcare Trust, Hammersmith Hospital, London, United Kingdom; Centre for Haematology, Faculty of Medicine, Imperial College London, London, United Kingdom
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15
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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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16
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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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17
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Recchia AG, Caruso N, Bossio S, Pellicanò M, De Stefano L, Franzese S, Palummo A, Abbadessa V, Lucia E, Gentile M, Vigna E, Caracciolo C, Agostino A, Galimberti S, Levato L, Stagno F, Molica S, Martino B, Vigneri P, Di Raimondo F, Morabito F. Flow Cytometric Immunobead Assay for Detection of BCR-ABL1 Fusion Proteins in Chronic Myleoid Leukemia: Comparison with FISH and PCR Techniques. PLoS One 2015; 10:e0130360. [PMID: 26111048 PMCID: PMC4482505 DOI: 10.1371/journal.pone.0130360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/18/2015] [Indexed: 11/19/2022] Open
Abstract
Chronic Myeloid Leukemia (CML) is characterized by a balanced translocation juxtaposing the Abelson (ABL) and breakpoint cluster region (BCR) genes. The resulting BCR-ABL1 oncogene leads to increased proliferation and survival of leukemic cells. Successful treatment of CML has been accompanied by steady improvements in our capacity to accurately and sensitively monitor therapy response. Currently, measurement of BCR-ABL1 mRNA transcript levels by real-time quantitative PCR (RQ-PCR) defines critical response endpoints. An antibody-based technique for BCR-ABL1 protein recognition could be an attractive alternative to RQ-PCR. To date, there have been no studies evaluating whether flow-cytometry based assays could be of clinical utility in evaluating residual disease in CML patients. Here we describe a flow-cytometry assay that detects the presence of BCR-ABL1 fusion proteins in CML lysates to determine the applicability, reliability, and specificity of this method for both diagnosis and monitoring of CML patients for initial response to therapy. We show that: i) CML can be properly diagnosed at onset, (ii) follow-up assessments show detectable fusion protein (i.e. relative mean fluorescent intensity, rMFI%>1) when BCR-ABL1IS transcripts are between 1-10%, and (iii) rMFI% levels predict CCyR as defined by FISH analysis. Overall, the FCBA assay is a rapid technique, fully translatable to the routine management of CML patients.
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Affiliation(s)
| | - Nadia Caruso
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Sabrina Bossio
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
| | | | | | - Stefania Franzese
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Angela Palummo
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
| | - Vincenzo Abbadessa
- Department of Oncology, Hematology and Bone Marrow Transplantation Unit, University of Palermo, Policlinico P. Giaccone, Palermo, Italy
| | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Clementina Caracciolo
- Department of Oncology, Hematology and Bone Marrow Transplantation Unit, University of Palermo, Policlinico P. Giaccone, Palermo, Italy
| | - Antolino Agostino
- Centro Trasfusionale Ospedale, Azienda Sanitaria Provinciale 7, Ragusa, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luciano Levato
- Medical Oncology Unit, Hematology-Oncology Department, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Fabio Stagno
- Divisione di Ematologia, Ospedale Ferrarotto, Università degli Studi di Catania, Catania, Italy
| | - Stefano Molica
- Medical Oncology Unit, Hematology-Oncology Department, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Bruno Martino
- U.O.C. di Ematologia dell'Azienda"Bianchi-Melacrino-Morelli" di Reggio Calabria, Reggio Calabria, Italy
| | - Paolo Vigneri
- Dipartimento di Scienze Mediche e Pediatriche, Università degli Studi di Catania, Catania, Italy
| | - Francesco Di Raimondo
- Divisione di Ematologia, Ospedale Ferrarotto, Università degli Studi di Catania, Catania, Italy
| | - Fortunato Morabito
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
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18
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Linhartova J, Hovorkova L, Soverini S, Benesova A, Jaruskova M, Klamova H, Zuna J, Machova Polakova K. Characterization of 46 patient-specific BCR-ABL1 fusions and detection of SNPs upstream and downstream the breakpoints in chronic myeloid leukemia using next generation sequencing. Mol Cancer 2015; 14:89. [PMID: 25928096 PMCID: PMC4409993 DOI: 10.1186/s12943-015-0363-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 04/08/2015] [Indexed: 11/22/2022] Open
Abstract
In chronic myeloid leukemia, the identification of individual BCR-ABL1 fusions is required for the development of personalized medicine approach for minimal residual disease monitoring at the DNA level. Next generation sequencing (NGS) of amplicons larger than 1000 bp simplified and accelerated a process of characterization of patient-specific BCR-ABL1 genomic fusions. NGS of large regions upstream and downstream the individual breakpoints in BCR and ABL1 genes, respectively, also provided information about the sequence variants such are single nucleotide polymorphisms.
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Affiliation(s)
- Jana Linhartova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic.
| | - Lenka Hovorkova
- CLIP, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, Prague, Czech Republic.
| | - Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology "L. e A. Seragnoli", University of Bologna, Bologna, Italy.
| | - Adela Benesova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic.
| | - Monika Jaruskova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic. .,Institute of Clinical and Experimental Hematology of First Faculty of Medicine and Institute of Hematology and Blood Transfusion, Charles University, Prague, Czech Republic.
| | - Hana Klamova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic. .,Institute of Clinical and Experimental Hematology of First Faculty of Medicine and Institute of Hematology and Blood Transfusion, Charles University, Prague, Czech Republic.
| | - Jan Zuna
- CLIP, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, Prague, Czech Republic.
| | - Katerina Machova Polakova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic. .,Institute of Clinical and Experimental Hematology of First Faculty of Medicine and Institute of Hematology and Blood Transfusion, Charles University, Prague, Czech Republic.
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19
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Abstract
In less than 10 years, the prognosis of chronic myeloid leukaemia has changed from that of a fatal disease to a disorder amenable simply to lifelong oral medication and compatible with a normal lifespan. This change has been made possible by a deep understanding of the molecular pathogenesis and a determination to develop targeted and selective drugs. This Seminar summarises the presentation, pathophysiology, diagnosis and monitoring technology, treatment options, side-effects, and outcomes of chronic myeloid leukaemia, and discusses the possibility of cure-ie, stable undetectable or low level disease in the absence of medication. Chronic myeloid leukaemia continues to instruct us in the mechanisms of leukaemogenesis and provides hope not only for similar developments in management of other malignancies, but also for the remarkable speed with which these can move from bench to bedside.
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Affiliation(s)
- Jane F Apperley
- Department of Haematology, Imperial College London, London, UK.
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20
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Molecular monitoring of chronic myeloid leukemia: principles and interlaboratory standardization. Ann Hematol 2015; 94 Suppl 2:S219-25. [PMID: 25814088 DOI: 10.1007/s00277-015-2315-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/28/2014] [Indexed: 01/08/2023]
Abstract
Serial quantification of BCR-ABL1 messenger RNA (mRNA) is an important therapeutic indicator for patients with chronic myeloid leukemia, but historically, there has been substantial variation in results reported by different laboratories. To help improve the comparability of results, an international scale (IS) for BCR-ABL1 was proposed which is being implemented by testing laboratories worldwide. This is being achieved most commonly by the derivation of laboratory-specific conversion factors, but increasingly by the use of kits or reagents that are calibrated to the first World Health Organization International Genetic Reference Panel for quantitation of BCR-ABL1 mRNA. Recent attention has focused on the need to define and validate levels of deeper molecular response (MR) within the context of the IS. While there has been substantial progress in the alignment of results, BCR-ABL1 measurement is technically challenging and standardization is an ongoing process.
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21
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Laboratory recommendations for scoring deep molecular responses following treatment for chronic myeloid leukemia. Leukemia 2015; 29:999-1003. [PMID: 25652737 PMCID: PMC4430701 DOI: 10.1038/leu.2015.29] [Citation(s) in RCA: 240] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 01/21/2015] [Indexed: 12/27/2022]
Abstract
Treatment of chronic myeloid leukemia (CML) with tyrosine kinase inhibitors has advanced to a stage where many patients achieve very low or undetectable levels of disease. Remarkably, some of these patients remain in sustained remission when treatment is withdrawn, suggesting that they may be at least operationally cured of their disease. Accurate definition of deep molecular responses (MRs) is therefore increasingly important for optimal patient management and comparison of independent data sets. We previously published proposals for broad standardized definitions of MR at different levels of sensitivity. Here we present detailed laboratory recommendations, developed as part of the European Treatment and Outcome Study for CML (EUTOS), to enable testing laboratories to score MR in a reproducible manner for CML patients expressing the most common BCR-ABL1 variants.
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22
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Bartley PA, Latham S, Budgen B, Ross DM, Hughes E, Branford S, White D, Hughes TP, Morley AA. A DNA real-time quantitative PCR method suitable for routine monitoring of low levels of minimal residual disease in chronic myeloid leukemia. J Mol Diagn 2014; 17:185-92. [PMID: 25554588 DOI: 10.1016/j.jmoldx.2014.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/15/2014] [Accepted: 10/20/2014] [Indexed: 12/20/2022] Open
Abstract
The BCR-ABL1 sequence has advantages over the BCR-ABL1 transcript as a molecular marker in chronic myeloid leukemia and has been used in research studies. We developed a DNA real-time quantitative PCR (qPCR) method for quantification of BCR-ABL1 sequences, which is also potentially suitable for routine use. The BCR-ABL1 breakpoint was sequenced after isolation by nested short-range PCR of DNA from blood, marrow, and cells on slides, obtained either at diagnosis or during treatment, or from artificial mixtures. PCR primers were chosen from a library of presynthesized and pretested BCR (n = 19) and ABL1 (n = 568) primers. BCR-ABL1 sequences were quantified relative to BCR sequences in 521 assays on 266 samples from 92 patients. For minimal residual disease detectable by DNA qPCR and RT-qPCR, DNA qPCR gave similar minimal residual disease results as RT-qPCR but had better precision at low minimal residual disease levels. The limit of detection of DNA qPCR depended on the amount of DNA assayed, being 10(-5.8) when 5 μg was assayed and 10(-7.0) when 80 μg was assayed. DNA qPCR may be useful and practical for monitoring the increasing number of patients with minimal residual disease around or below the limit of detection of RT-qPCR as the assay itself is simple and the up-front costs will be amortized if sequential assays are performed.
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Affiliation(s)
- Paul A Bartley
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Susan Latham
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Bradley Budgen
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - David M Ross
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia; Haematology Division, SA Pathology, Adelaide, South Australia, Australia
| | - Elizabeth Hughes
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Susan Branford
- Centre for Cancer Biology, SA Pathology, Adelaide, South Australia, Australia
| | - Deborah White
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Timothy P Hughes
- Haematology Division, SA Pathology, Adelaide, South Australia, Australia
| | - Alexander A Morley
- Department of Haematology and Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia; Monoquant Pty. Ltd., Adelaide, South Australia, Australia.
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23
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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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24
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Abstract
More and more potent therapeutic approaches demand more and more sophisticated response monitoring. Soon after the introduction of the first tyrosine-kinase inhibitor (TKI) for chronic myeloid leukemia (CML) treatment, real time quantitative polymerase chain reaction (RQ-PCR) became the gold standard to follow the kinetics of reduction of disease burden and allow prognostic stratification. Continuous therapeutic improvement has led to increasingly ambitious treatment endpoints (now culminating in the possibility of achieving treatment free remission), which, in turn, has led to more and more refined measurement and definition of molecular response (MR) levels. Here, we will review the evolution of molecular response definitions and terminology, how specific MR levels currently provide key checkpoints in the context of optimal patient management, how molecular monitoring can best be performed nowadays and what future trends for further technological improvement can be.
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Pagani IS, Spinelli O, Mattarucchi E, Pirrone C, Pigni D, Amelotti E, Lilliu S, Boroni C, Intermesoli T, Giussani U, Caimi L, Bolda F, Baffelli R, Candi E, Pasquali F, Lo Curto F, Lanfranchi A, Porta F, Rambaldi A, Porta G. Genomic quantitative real-time PCR proves residual disease positivity in more than 30% samples with negative mRNA-based qRT-PCR in Chronic Myeloid Leukemia. Oncoscience 2014; 1:510-21. [PMID: 25594053 PMCID: PMC4278316 DOI: 10.18632/oncoscience.65] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/23/2014] [Indexed: 12/20/2022] Open
Abstract
Imatinib mesylate (IM) is the first line therapy against Chronic Myeloid Leukemia, effectively prolonging overall survival. Because discontinuation of treatment is associated with relapse, IM is required indefinitely to maintain operational cure. To assess minimal residual disease, cytogenetic analysis is insensitive in a high background of normal lymphocytes. The qRT-PCR provides highly sensitive detection of BCR-ABL1 transcripts, but mRNA levels are not directly related to the number of leukemic cells, and undetectable results are difficult to interpret. We developed a sensitive approach to detect the number of leukemic cells by a genomic DNA (gDNA) Q-PCR assay based on the break-point sequence, with a formula to calculate the number of Ph-positive cells. We monitored 8 CML patients treated with IM for more than 8 years. We tested each samples by patient specific gDNA Q-PCR in parallel by the conventional techniques. In all samples positive for chimeric transcripts we showed corresponding chimeric gDNA by Q-PCR, and in 32.8% (42/128) of samples with undetectable levels of mRNA we detected the persistence of leukemic cells. The gDNA Q-PCR assay could be a new diagnostic tool used in parallel to conventional techniques to support the clinician's decision to vary or to STOP IM therapy.
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Affiliation(s)
- Ilaria S Pagani
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy ; Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Orietta Spinelli
- Hematology laboratory, USC Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Elia Mattarucchi
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Cristina Pirrone
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Diana Pigni
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Elisabetta Amelotti
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Silvia Lilliu
- Hematology laboratory, USC Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Chiara Boroni
- Hematology laboratory, USC Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Tamara Intermesoli
- Hematology laboratory, USC Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ursula Giussani
- Laboratory of Medical Genetics, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Caimi
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Federica Bolda
- Laboratory of chemical-clinical analysis, Section of Hematology and blood coagulation, Stem Cells laboratory, Spedali Civili of Brescia, Brescia, Italy
| | - Renata Baffelli
- Laboratory of chemical-clinical analysis, Section of Hematology and blood coagulation, Stem Cells laboratory, Spedali Civili of Brescia, Brescia, Italy
| | - Eleonora Candi
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Francesco Pasquali
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Francesco Lo Curto
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
| | - Arnalda Lanfranchi
- Laboratory of chemical-clinical analysis, Section of Hematology and blood coagulation, Stem Cells laboratory, Spedali Civili of Brescia, Brescia, Italy
| | - Fulvio Porta
- Laboratory of chemical-clinical analysis, Section of Hematology and blood coagulation, Stem Cells laboratory, Spedali Civili of Brescia, Brescia, Italy
| | - Alessandro Rambaldi
- Hematology laboratory, USC Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giovanni Porta
- Department of Experimental and Clinical Medicine, Insubria University, Varese, Italy
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JAK2/STAT5 inhibition by nilotinib with ruxolitinib contributes to the elimination of CML CD34+ cells in vitro and in vivo. Blood 2014; 124:1492-501. [PMID: 24957147 DOI: 10.1182/blood-2013-12-545640] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic myeloid leukemia (CML) stem cell survival is not dependent on BCR-ABL protein kinase and treatment with ABL tyrosine kinase inhibitors cures only a minority of CML patients, thus highlighting the need for novel therapeutic targets. The Janus kinase (JAK)2/signal transducer and activator of transcription (STAT)5 pathway has recently been explored for providing putative survival signals to CML stem/progenitor cells (SPCs) with contradictory results. We investigated the role of this pathway using the JAK2 inhibitor, ruxolitinib (RUX). We demonstrated that the combination of RUX, at clinically achievable concentrations, with the specific and potent tyrosine kinase inhibitor nilotinib, reduced the activity of the JAK2/STAT5 pathway in vitro relative to either single agent alone. These effects correlated with increased apoptosis of CML SPCs in vitro and a reduction in primitive quiescent CML stem cells, including NOD.Cg-Prkdc(scid) IL2rg(tm1Wjl) /SzJ mice repopulating cells, induced by combination treatment. A degree of toxicity toward normal SPCs was observed with the combination treatment, although this related to mature B-cell engraftment in NOD.Cg-Prkdc(scid) IL2rg(tm1Wjl) /SzJ mice with minimal effects on primitive CD34(+) cells. These results support the JAK2/STAT5 pathway as a relevant therapeutic target in CML SPCs and endorse the current use of nilotinib in combination with RUX in clinical trials to eradicate persistent disease in CML patients.
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Baccarani M, Castagnetti F, Gugliotta G, Palandri F, Rosti G. Definition and treatment of resistance to tyrosine kinase inhibitors in chronic myeloid leukemia. Expert Rev Hematol 2014; 7:397-406. [PMID: 24665926 DOI: 10.1586/17474086.2014.900432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Resistance to tyrosine kinase inhibitors (TKIs) has many facets. The causes of resistance include low patient compliance, low plasma or intracellular drug concentration, BCR-ABL1 mutations, and clonal chromosome abnormalities in Ph+ cells, but in at least 50% of patients the causes are currently unknown. Primary resistance occurs when a predefined response level is not achieved within a prespecified period of time. Not achieving a complete hematologic response (CHR) within 3 months, not achieving a partial cytogenetic response and/or a BCR-ABL1 transcripts level ≤10% (international standard) within 6 months, and not achieving a complete cytogenetic response (CCyR) and/or a BCR-ABL1 transcripts level <1% within 12 months, define primary resistance. Secondary resistance is defined by a loss of CHR, or CCyR, or major molecular response. Resistance to imatinib calls without exceptions for a second-generation TKI. In case of resistance to two TKIs, an allogeneic stem cell transplantation should be considered.
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Affiliation(s)
- Michele Baccarani
- Department of Hematology and Oncology "L. and A. Seràgnoli", Bologna, Italy
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28
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Ichim CV. Kinase-independent mechanisms of resistance of leukemia stem cells to tyrosine kinase inhibitors. Stem Cells Transl Med 2014; 3:405-15. [PMID: 24598782 DOI: 10.5966/sctm.2012-0159] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Tyrosine kinase inhibitors such as imatinib mesylate have changed the clinical course of chronic myeloid leukemia; however, the observation that these inhibitors do not target the leukemia stem cell implies that patients need to maintain lifelong therapy. The mechanism of this phenomenon is unclear: the question of whether tyrosine kinase inhibitors are inactive inside leukemia stem cells or whether leukemia stem cells do not require breakpoint cluster region (Bcr)-Abl signaling is currently under debate. Herein, I propose an alternative model: perhaps the leukemia stem cell requires Bcr-Abl, but is dependent on its kinase-independent functions. Kinases such as epidermal growth factor receptor and Janus kinase 2 possess kinase-independent roles in regulation of gene expression; it is worth investigating whether Bcr-Abl has similar functions. Mechanistically, Bcr-Abl is able to activate the Ras, phosphatidylinositol 3-kinase/Akt, and/or the Src-kinase Hck/Stat5 pathways in a scaffolding-dependent manner. Whereas the scaffolding activity of Bcr-Abl with Grb2 is dependent on autophosphorylation, kinases such as Hck can use Bcr-Abl as substrate, inducing phosphorylation of Y177 to enable scaffolding ability in the absence of Bcr-Abl catalytic activity. It is worth investigating whether leukemia stem cells exclusively express kinases that are able to use Bcr-Abl as substrate. A kinase-independent role for Bcr-Abl in leukemia stem cells would imply that drugs that target Bcr-Abl's scaffolding ability or its DNA-binding ability should be used in conjunction with current therapeutic regimens to increase their efficacy and eradicate the stem cells of chronic myeloid leukemia.
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MESH Headings
- Animals
- Drug Resistance, Neoplasm
- Gene Expression Regulation, Leukemic/drug effects
- Gene Expression Regulation, Leukemic/genetics
- Humans
- Leukemia
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Neoplasm Proteins/antagonists & inhibitors
- Neoplasm Proteins/genetics
- Neoplasm Proteins/metabolism
- Neoplastic Stem Cells/enzymology
- Neoplastic Stem Cells/pathology
- Phosphatidylinositol 3-Kinases/genetics
- Phosphatidylinositol 3-Kinases/metabolism
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Protein-Tyrosine Kinases/genetics
- Protein-Tyrosine Kinases/metabolism
- Signal Transduction/drug effects
- Signal Transduction/genetics
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Affiliation(s)
- Christine Victoria Ichim
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Discipline of Molecular and Cellular Biology, Sunnybrook Research Institute, Toronto, Ontario, Canada
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Jennings LJ, George D, Czech J, Yu M, Joseph L. Detection and Quantification of BCR-ABL1 Fusion Transcripts by Droplet Digital PCR. J Mol Diagn 2014; 16:174-9. [DOI: 10.1016/j.jmoldx.2013.10.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/04/2013] [Accepted: 10/24/2013] [Indexed: 12/20/2022] Open
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30
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Striving to achieve safe, permanent treatment discontinuation in chronic myeloid leukemia. Leuk Res 2013; 37:1395-403. [DOI: 10.1016/j.leukres.2013.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/19/2013] [Indexed: 12/11/2022]
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31
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Neviani P, Harb JG, Oaks JJ, Santhanam R, Walker CJ, Ellis JJ, Ferenchak G, Dorrance AM, Paisie CA, Eiring AM, Ma Y, Mao HC, Zhang B, Wunderlich M, May PC, Sun C, Saddoughi SA, Bielawski J, Blum W, Klisovic RB, Solt JA, Byrd JC, Volinia S, Cortes J, Huettner CS, Koschmieder S, Holyoake TL, Devine S, Caligiuri MA, Croce CM, Garzon R, Ogretmen B, Arlinghaus RB, Chen CS, Bittman R, Hokland P, Roy DC, Milojkovic D, Apperley J, Goldman JM, Reid A, Mulloy JC, Bhatia R, Marcucci G, Perrotti D. PP2A-activating drugs selectively eradicate TKI-resistant chronic myeloid leukemic stem cells. J Clin Invest 2013; 123:4144-57. [PMID: 23999433 DOI: 10.1172/jci68951] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 07/03/2013] [Indexed: 12/26/2022] Open
Abstract
The success of tyrosine kinase inhibitors (TKIs) in treating chronic myeloid leukemia (CML) depends on the requirement for BCR-ABL1 kinase activity in CML progenitors. However, CML quiescent HSCs are TKI resistant and represent a BCR-ABL1 kinase-independent disease reservoir. Here we have shown that persistence of leukemic HSCs in BM requires inhibition of the tumor suppressor protein phosphatase 2A (PP2A) and expression--but not activity--of the BCR-ABL1 oncogene. Examination of HSCs from CML patients and healthy individuals revealed that PP2A activity was suppressed in CML compared with normal HSCs. TKI-resistant CML quiescent HSCs showed increased levels of BCR-ABL1, but very low kinase activity. BCR-ABL1 expression, but not kinase function, was required for recruitment of JAK2, activation of a JAK2/β-catenin survival/self-renewal pathway, and inhibition of PP2A. PP2A-activating drugs (PADs) markedly reduced survival and self-renewal of CML quiescent HSCs, but not normal quiescent HSCs, through BCR-ABL1 kinase-independent and PP2A-mediated inhibition of JAK2 and β-catenin. This led to suppression of human leukemic, but not normal, HSC/progenitor survival in BM xenografts and interference with long-term maintenance of BCR-ABL1-positive HSCs in serial transplantation assays. Targeting the JAK2/PP2A/β-catenin network in quiescent HSCs with PADs (e.g., FTY720) has the potential to treat TKI-refractory CML and relieve lifelong patient dependence on TKIs.
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32
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Baccarani M, Deininger MW, Rosti G, Hochhaus A, Soverini S, Apperley JF, Cervantes F, Clark RE, Cortes JE, Guilhot F, Hjorth-Hansen H, Hughes TP, Kantarjian HM, Kim DW, Larson RA, Lipton JH, Mahon FX, Martinelli G, Mayer J, Müller MC, Niederwieser D, Pane F, Radich JP, Rousselot P, Saglio G, Saußele S, Schiffer C, Silver R, Simonsson B, Steegmann JL, Goldman JM, Hehlmann R. European LeukemiaNet recommendations for the management of chronic myeloid leukemia: 2013. Blood 2013; 122:872-84. [PMID: 23803709 PMCID: PMC4915804 DOI: 10.1182/blood-2013-05-501569] [Citation(s) in RCA: 1417] [Impact Index Per Article: 128.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/10/2013] [Indexed: 02/07/2023] Open
Abstract
Advances in chronic myeloid leukemia treatment, particularly regarding tyrosine kinase inhibitors, mandate regular updating of concepts and management. A European LeukemiaNet expert panel reviewed prior and new studies to update recommendations made in 2009. We recommend as initial treatment imatinib, nilotinib, or dasatinib. Response is assessed with standardized real quantitative polymerase chain reaction and/or cytogenetics at 3, 6, and 12 months. BCR-ABL1 transcript levels ≤10% at 3 months, <1% at 6 months, and ≤0.1% from 12 months onward define optimal response, whereas >10% at 6 months and >1% from 12 months onward define failure, mandating a change in treatment. Similarly, partial cytogenetic response (PCyR) at 3 months and complete cytogenetic response (CCyR) from 6 months onward define optimal response, whereas no CyR (Philadelphia chromosome-positive [Ph+] >95%) at 3 months, less than PCyR at 6 months, and less than CCyR from 12 months onward define failure. Between optimal and failure, there is an intermediate warning zone requiring more frequent monitoring. Similar definitions are provided for response to second-line therapy. Specific recommendations are made for patients in the accelerated and blastic phases, and for allogeneic stem cell transplantation. Optimal responders should continue therapy indefinitely, with careful surveillance, or they can be enrolled in controlled studies of treatment discontinuation once a deeper molecular response is achieved.
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Affiliation(s)
- Michele Baccarani
- Department of Hematology L. and A. Seràgnoli, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy.
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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: 543] [Impact Index Per Article: 49.4] [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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34
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Distribution of genomic breakpoints in chronic myeloid leukemia: analysis of 308 patients. Leukemia 2013; 27:2105-7. [PMID: 23588714 DOI: 10.1038/leu.2013.116] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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35
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Abstract
Abstract
Monitoring response to therapy for patients with chronic myeloid leukemia using an effective strategy is fundamental for achieving optimal patient outcomes. It will allow the initiation of timely therapeutic intervention for patients with a suboptimal response or kinase inhibitor therapy failure. Evidence is mounting that reaching molecular targets early in therapy is as important as the initial hematologic and cytogenetic response for the identification of patients who may have a poorer outcome. When the molecular target of a major molecular response is achieved at 18 months, patients reach a safe haven where loss of response is rare. However, this benefit is dependent on continuous drug adherence in most patients. As some patients reach their second decade of successful imatinib therapy, how long will frequent response monitoring be necessary? Assuming that very late relapse will be extremely rare for responding patients remaining on kinase inhibitor therapy, there are reasons for maintaining a regular molecular monitoring frequency, including monitoring adherence assessment and confirming sustained undetectable BCR-ABL1 for those considering a discontinuation trial and for late molecular recurrence in patients who maintain response after treatment discontinuation.
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36
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Identification of the genomic BCR-ABL1 fusion sequence from blood specimen stored on filter paper. Leuk Res 2012; 37:117-9. [PMID: 23127356 DOI: 10.1016/j.leukres.2012.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/09/2012] [Indexed: 11/22/2022]
Abstract
Chronic myeloid leukaemia (CML) is characterized by the Philadelphia chromosome resulting in the BCR-ABL1 gene whose mRNA transcript detection is commonly used for diagnosis and monitoring of therapeutic response. However, in collected blood specimen degradation of mRNA has to be considered during storage and transport thus jeopardizing the analysis. We here describe an alternative DNA-based technique applied after long-term blood storage. DNA was isolated from dried blood stains from CML patients stored on filter paper (Guthrie cards) after a median period from diagnosis of 11 years (range: 5-12 years) and analyzed with a two round long-range multiplex PCR (MLR-PCR) to identify the genomic BCR-ABL1 breakpoint. Patient-specific individual BCR-ABL1 fusion sites were successfully detected in 10 out of 13 patients. Dried blood stains represent a valuable resource for genomic DNA analyses. Long term preservation is easily manageable in paper envelopes with the patient's medical files with a minimum of financial costs and efforts. Such the cooperation between laboratories and hospitals separated by long distances is facilitated rendering possible offering specialized genomic analyses to patients with CML virtually everywhere around the world. This technique may also be a valuable approach for diagnostic procedures on a high molecular level in related haematological malignancies.
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Krumbholz M, Karl M, Tauer JT, Thiede C, Rascher W, Suttorp M, Metzler M. Genomic BCR-ABL1 breakpoints in pediatric chronic myeloid leukemia. Genes Chromosomes Cancer 2012; 51:1045-53. [PMID: 22887688 DOI: 10.1002/gcc.21989] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 07/01/2012] [Indexed: 12/16/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a rare disease in children and adolescents and various aspects-from molecular genesis to therapy regimen-have been taken over from studies on the more prevalent adult CML. However, differences have been observed between malignancies with identical underlying chromosomal translocations, but occurring at different age groups, suggesting some diversity in the mechanisms of formation and leukemogenesis. A multiplex long-range PCR-based assay was developed to allow fast and reliable amplification of patient-specific BCR-ABL1 fusion sequences from genomic DNA. The localization of breakpoints was analyzed with respect to distribution within the breakpoint cluster regions, sequence features, and association to repetitive elements or motifs associated with DNA recombination. The genomic fusion sites of 59 pediatric CML patients showed a bimodal breakpoint distribution in BCR that was different from the distribution in adult CML cases, but with similarities to BCR-ABL1-positive, acute lymphoblastic leukemia in adults. BCR breakpoints were found more frequently positioned within, or close to, Alu repeats than would be expected based on their overall sequence proportion. Technical aspects of the highly sensitive DNA-based quantification of residual CML cells by specific fusion sequence during tyrosine kinase inhibitor therapy are exemplified in a subcohort of pediatric CML patients.
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Jabbour EJ, Quintás-Cardama A. Molecular monitoring 101: helping your patients with chronic myeloid leukemia to understand the meaning of molecular response. Leuk Lymphoma 2012; 53:1452-60. [PMID: 22273251 DOI: 10.3109/10428194.2012.659734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
For patients with chronic myeloid leukemia (CML), measurement of molecular response (i.e. the level of BCR-ABL1 transcripts) is firmly established as a key element of disease monitoring. Assessment of BCR-ABL1 levels may help to identify early signs of resistance to treatment and enable a timely switch to alternative therapies. Hence, regular and accurate monitoring of BCR-ABL1 transcripts helps to maximize the chance of successful outcomes in CML. Because the incidence of CML is relatively low, many community oncologists encounter only a limited number of cases; measuring and interpreting BCR-ABL1 measurements in a clinically relevant fashion may be challenging. The team at our institution often encounters questions regarding real-time quantitative polymerase chain reaction assessments of BCR-ABL1 levels, International Scale standardization, the implications of achieving or losing molecular responses and mutation monitoring. The aim of this article is to provide practical advice for effective long-term monitoring of patients with CML by addressing frequently asked questions and common case scenarios using guideline- and evidence-based approaches.
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Affiliation(s)
- Elias J Jabbour
- Department of Leukemia, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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39
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Perrotti D. Where are we going with CML research? Leuk Suppl 2012; 1:S51-3. [PMID: 27175251 DOI: 10.1038/leusup.2012.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The introduction of Abl tyrosine kinase inhibitors (TKI; that is, imatinib, dasatinib and nilotinib) as front-line therapy completely changed the course of chronic myelogenous leukemia (CML) to the point that most of the TKI-responsive newly diagnosed CML patients can be considered 'clinically' cured and their progression into blast crisis (BC) a rare event. However, a therapy for those patients who transform is still lacking, and TKIs do not eradicate CML at the stem cell level, therefore leaving a reservoir of cancer stem cells in a dormant stage. Thus, it is not surprising that the focus of CML research has shifted significantly toward the dissection of the mechanisms regulating the survival and self-renewal of TKI-resistant Philadelphia-positive leukemic chronic phase and BC stem cells, with the ultimate goal of developing small molecules capable of selectively killing leukemic but not normal hematopoietic stem cells, thereby achieving a 'biological' cure for this disease.
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Affiliation(s)
- D Perrotti
- Department of Microbiology, Immunology and Medical Genetics, Comprehensive Cancer Center, The Ohio State University , Columbus, OH, USA
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40
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Esmailzadeh S, Jiang X. AHI-1: a novel signaling protein and potential therapeutic target in human leukemia and brain disorders. Oncotarget 2012; 2:918-34. [PMID: 22248740 PMCID: PMC3282096 DOI: 10.18632/oncotarget.405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Progress in the understanding of the molecular and cellular mechanisms of human cancer, including human leukemia and lymphomas, has been spurred by cloning of fusion genes created by chromosomal translocations or by retroviral insertional mutagenesis; a number of oncogenes and tumor suppressors involved in development of a number of malignancies have been identified in this manner. The BCR-ABL fusion gene, originating in a multipotent hematopoietic stem cell, is the molecular signature of chronic myeloid leukemia (CML). Discovery of this fusion gene has led to the development of one of the first successful targeted molecular therapies for cancer (Imatinib). It illustrates the advances that can result from an understanding of the molecular basis of disease. However, there still remain many as yet unidentified mutations that may influence the initiation or progression of human diseases. Thus, identification and characterization of the mechanism of action of genes that contribute to human diseases is an important and opportune area of current research. One promising candidate as a potential therapeutic target is Abelson helper integration site-1(Ahi-1/AHI-1) that was identified by retroviral insertional mutagenesis in murine models of leukemia/lymphomas and is highly elevated in certain human lymphoma and leukemia stem/progenitor cells. It encodes a unique protein with a SH3 domain, multiple SH3 binding sites and a WD40-repeat domain, suggesting that the normal protein has novel signaling activities. A new AHI-1-BCR-ABL-JAK2 interaction complex has recently been identified and this complex regulates transforming activities and drug resistance in CML stem/progenitor cells. Importantly, AHI-1 has recently been identified as a susceptibility gene involved in a number of brain disorders, including Joubert syndrome. Therefore, understanding molecular functions of the AHI-1 gene could lead to important and novel insights into disease processes involved in specific types of diseases. Ultimately, this knowledge will set the stage for translation into new and more effective diagnostic and treatment strategies.
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Affiliation(s)
- Sharmin Esmailzadeh
- Terry Fox Laboratory, British Columbia Cancer Agency and Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
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Chomel JC, Turhan AG. Chronic myeloid leukemia stem cells in the era of targeted therapies: resistance, persistence and long-term dormancy. Oncotarget 2012; 2:713-27. [PMID: 21946665 PMCID: PMC3248215 DOI: 10.18632/oncotarget.333] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Targeted therapies of chronic myeloid leukemia (CML) using tyrosine kinase inhibitors (TKI) have profoundly changed the natural history of the disease with a major impact on survival. Molecular monitoring with BCR-ABL quantification shows that a status of undetectable molecular residual disease (UMRD) is obtained in a significant minority of patients. However, it remains unclear whether these patients are definitively cured of their leukemia. Imatinib mesylate withdrawal trials have demonstrated the rapid appearance of the malignant clone in the majority of the patients whereas some patients remain in a state of UMRD. It has clearly been demonstrated that the most primitive stem cells are refractory to all TKIs used in clinical practice. In addition, long-term dormancy is one of the most fundamental characteristics of hematopoietic stem cells. In this context, we have recently undertaken a systematic analysis of the bone marrow stem cell compartment in several patients in durable UMRD. We have demonstrated the long-term persistence of a considerable amount of BCR-ABL-expressing stem cells, even in the absence of relapse. The phenomenon of long-term leukemic stem cell dormancy is of major importance in CML and one of the key questions in cancer biology in general. We discuss, here, the potential mechanisms, including intrinsic and microenvironmental factors, that control the response of leukemic stem cells (LSCs) to targeted therapies and potential novel strategies currently in progress with a curative intent. Moreover, we propose a molecular evaluation of the residual LSC compartment in selected patients in order to develop rational TKI-cessation strategies in CML.
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Affiliation(s)
- Jean-Claude Chomel
- Service d'Hématologie et Oncologie Biologique, CHU de Poitiers, Université de Poitiers, France
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Abstract
The International Randomized Study of Interferon and STI571 (IRIS) demonstrated long-term cytogenetic responses in patients with chronic-phase chronic myeloid leukemia (CML-CP) treated with the tyrosine kinase inhibitor (TKI) imatinib. However, deep molecular responses (MRs), as measured by reductions in BCR-ABL transcript levels below the threshold of major MR, were achieved only by a small proportion of patients. With the advent of the second-generation TKIs nilotinib and dasatinib for the treatment of patients with newly diagnosed CML-CP, the proportion of patients who achieve the deepest levels of MR is likely to increase significantly. With these changes, the potential for patient eligibility in TKI cessations studies is becoming a more widely discussed topic and area for research. These developments highlight the need for robust, standardized and workable definitions of deep MRs. Specifically, it is critical that the measurement of MR is standardized in a manner to withstand both intra- and inter-laboratory variability, as well as new methodological developments. This review summarizes the relevant clinical background and proposes a framework within which standardization of MR can be taken forward.
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Chronic myeloid leukemia stem cells are not dependent on Bcr-Abl kinase activity for their survival. Blood 2011; 119:1501-10. [PMID: 22184410 DOI: 10.1182/blood-2010-12-326843] [Citation(s) in RCA: 314] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recent evidence suggests chronic myeloid leukemia (CML) stem cells are insensitive to kinase inhibitors and responsible for minimal residual disease in treated patients. We investigated whether CML stem cells, in a transgenic mouse model of CML-like disease or derived from patients, are dependent on Bcr-Abl. In the transgenic model, after retransplantation, donor-derived CML stem cells in which Bcr-Abl expression had been induced and subsequently shut off were able to persist in vivo and reinitiate leukemia in secondary recipients on Bcr-Abl reexpression. Bcr-Abl knockdown in human CD34(+) CML cells cultured for 12 days in physiologic growth factors achieved partial inhibition of Bcr-Abl and downstream targets p-CrkL and p-STAT5, inhibition of proliferation and colony forming cells, but no reduction of input cells. The addition of dasatinib further inhibited p-CrkL and p-STAT5, yet only reduced input cells by 50%. Complete growth factor withdrawal plus dasatinib further reduced input cells to 10%; however, the surviving fraction was enriched for primitive leukemic cells capable of growth in a long-term culture-initiating cell assay and expansion on removal of dasatinib and addition of growth factors. Together, these data suggest that CML stem cell survival is Bcr-Abl kinase independent and suggest curative approaches in CML must focus on kinase-independent mechanisms of resistance.
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Current world literature. Curr Opin Oncol 2011; 23:700-9. [PMID: 21993416 DOI: 10.1097/cco.0b013e32834d384a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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]
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Branford S, Prime J. Chronic myelogenous leukemia: monitoring response to therapy. Curr Hematol Malig Rep 2011; 6:75-81. [PMID: 21360071 DOI: 10.1007/s11899-011-0082-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Molecular monitoring is a key component of the management of patients with chronic myeloid leukemia. The current recommendation is that molecular monitoring be performed in place of cytogenetic assessment when a major molecular response (MMR) is achieved. With the more potent kinase inhibitors nilotinib and dasatinib now approved as front-line therapy, more patients will achieve an MMR and will benefit from molecular monitoring. There is a strong correlation between certain BCR-ABL1 levels and the cytogenetic response, which means that molecular monitoring may act as a surrogate for cytogenetic response, but only if the BCR-ABL1 values are converted to the international reporting scale. Furthermore, improvements in the limit of BCR-ABL1 detection and reduction of intra-assay variability are ongoing issues of importance for molecular monitoring. Standardization of molecular methods to accurately assess the patient response also remains a challenge, despite the recent certification of international scale reference materials.
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Affiliation(s)
- Susan Branford
- Department of Molecular Pathology, Centre for Cancer Biology, SA Pathology and the University of Adelaide, Adelaide, Australia.
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Persistence of leukemia stem cells in chronic myelogenous leukemia patients in prolonged remission with imatinib treatment. Blood 2011; 118:5565-72. [PMID: 21931114 DOI: 10.1182/blood-2010-12-327437] [Citation(s) in RCA: 193] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Imatinib mesylate treatment markedly reduces the burden of leukemia cells in chronic myelogenous leukemia (CML) patients. However, patients remain at risk for relapse on discontinuing treatment. We have previously shown that residual BCR-ABL(+) progenitors can be detected in CML patients within the first 2 years of imatinib treatment. However, reduced rates of relapse and continued decline of BCR-ABL levels with prolonged treatment, together with the ability of selected patients to maintain remission after discontinuing treatment, led us to investigate whether prolonged imatinib exposure resulted in reduction or elimination of BCR-ABL(+) stem cells. We evaluated BCR-ABL expression in CD34(+)CD38(+) (38(+)) committed progenitors and CD34(+)CD38(-) (38(-)) stem/primitive progenitor cells in samples from CML patients on imatinib treatment for at least 4 years with cytogenetic and molecular response. High levels of BCR-ABL expression were maintained over time in the 38(-) stem cell fraction. The absolute frequency of BCR-ABL(+) cells as determined by limiting dilution analysis was consistently higher in 38(-) compared with 38(+) cells. Transplantation into NOD/SCID-IL2Rγ-chain knockout mice demonstrated that BCR-ABL(+) cells had long-term in vivo repopulating capacity. These results directly demonstrate that BCR-ABL(+) stem cells persist in CML patients despite prolonged treatment with imatinib, and support ongoing efforts to target this population.
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Ross DM, Bartley PA, Goyne J, Morley AA, Seymour JF, Grigg AP. Durable complete molecular remission of chronic myeloid leukemia following dasatinib cessation, despite adverse disease features. Haematologica 2011; 96:1720-2. [PMID: 21828123 DOI: 10.3324/haematol.2011.048165] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Patients with chronic myeloid leukemia, treated with imatinib, who have a durable complete molecular response, might remain in complete molecular response after stopping treatment. Previous reports of patients stopping treatment in complete molecular response have included only patients with a good response to imatinib. We describe 3 patients with stable complete molecular response on dasatinib treatment following imatinib failure. Two of the 3 patients remain in complete molecular response more than 12 months after stopping dasatinib. In these 2 patients we used highly sensitive patient-specific BCR-ABL1 DNA PCR to show that the leukemic clone remains detectable, as we have previously shown in imatinib-treated patients. Dasatinib-associated immunological phenomena, such as the emergence of clonal T-cell populations, were observed both in one patient who relapsed and in one patient in remission. Our results suggest that the characteristics of complete molecular response on dasatinib treatment may be similar to that achieved with imatinib, at least in patients with adverse disease features.
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Affiliation(s)
- David M Ross
- Dept of Haematology, SA Pathology, and School of Medicine, University of Adelaide, Adelaide, Australia.
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Leukemic stem cell persistence in chronic myeloid leukemia patients with sustained undetectable molecular residual disease. Blood 2011; 118:3657-60. [PMID: 21791426 DOI: 10.1182/blood-2011-02-335497] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sustained undetectable molecular residual disease (UMRD) is obtained in a minority of patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors. It remains unclear whether these patients are definitively cured of their leukemia or whether leukemic stem cells (LSCs) persist in their BM. We have evaluated the presence of BCR-ABL-expressing marrow LSCs in 6 patients with chronic myeloid leukemia with sustained UMRD induced by IFN-α (n = 3), imatinib mesylate after IFN-α failure (n = 2), and dasatinib after imatinib intolerance (n = 1). Purified CD34(+) cells were used for clonogenic and long-term culture-initiating cell assays performed on classic or HOXB4-expressing MS-5 feeders. Using this strategy, we identified BCR-ABL-expressing LSCs in all patients. Interestingly, long-term culture-initiating cell assays with MS-5/HOXB4 stromal feeders increased detected numbers of LSCs in 3 patients. The relation between LSC persistency and a potential risk of disease relapse for patients with durable UMRD (on or off tyrosine kinase inhibitor therapy) warrants further investigation.
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