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Li X, Li W, Zhang Y, Xu L, Song Y. Exploiting the potential of the ubiquitin-proteasome system in overcoming tyrosine kinase inhibitor resistance in chronic myeloid leukemia. Genes Dis 2024; 11:101150. [PMID: 38947742 PMCID: PMC11214299 DOI: 10.1016/j.gendis.2023.101150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/15/2023] [Accepted: 09/01/2023] [Indexed: 07/02/2024] Open
Abstract
The advent of tyrosine kinase inhibitors (TKI) targeting BCR-ABL has drastically changed the treatment approach of chronic myeloid leukemia (CML), greatly prolonged the life of CML patients, and improved their prognosis. However, TKI resistance is still a major problem with CML patients, reducing the efficacy of treatment and their quality of life. TKI resistance is mainly divided into BCR-ABL-dependent and BCR-ABL-independent resistance. Now, the main clinical strategy addressing TKI resistance is to switch to newly developed TKIs. However, data have shown that these new drugs may cause serious adverse reactions and intolerance and cannot address all resistance mutations. Therefore, finding new therapeutic targets to overcome TKI resistance is crucial and the ubiquitin-proteasome system (UPS) has emerged as a focus. The UPS mediates the degradation of most proteins in organisms and controls a wide range of physiological processes. In recent years, the study of UPS in hematological malignant tumors has resulted in effective treatments, such as bortezomib in the treatment of multiple myeloma and mantle cell lymphoma. In CML, the components of UPS cooperate or antagonize the efficacy of TKI by directly or indirectly affecting the ubiquitination of BCR-ABL, interfering with CML-related signaling pathways, and negatively or positively affecting leukemia stem cells. Some of these molecules may help overcome TKI resistance and treat CML. In this review, the mechanism of TKI resistance is briefly described, the components of UPS are introduced, existing studies on UPS participating in TKI resistance are listed, and UPS as the therapeutic target and strategies are discussed.
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Affiliation(s)
- Xudong Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan 450008, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Wei Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Yanli Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Linping Xu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan 450008, China
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan 450008, China
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
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2
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Cui Y, Li Y, Ji J, Hu N, Min K, Ying W, Fan L, Hong M, Li J, Sun Z, Qu X. Dynamic Single-Cell RNA-Seq reveals mechanism of Selinexor-Resistance in Chronic myeloid leukemia. Int Immunopharmacol 2024; 134:112212. [PMID: 38728882 DOI: 10.1016/j.intimp.2024.112212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/23/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024]
Abstract
Chronic myeloid leukemia (CML) is a type of hematologic malignancies caused by BCR-ABL chimeric oncogene. Resistance to tyrosine kinase inhibitors (TKIs) leads to the progression of CML into advanced stages. Selinexor is a small molecule inhibitor that targets a nuclear transporter called Exportin 1. Combined with imatinib, selinexor has been shown to disrupt nuclear-cytoplasmic transport signal of leukemia stem cells, resulting in cell death. The objective of this study was to investigate the mechanism of drug resistance to selinexor in CML. We established K562 cell line resistant to selinexor and conducted single cell dynamic transcriptome sequencing to analyze the heterogeneity within the parental and selinexor resistant cell populations. We identified specific gene expression changes associated with resistance to selinexor. Our results revealed differential expression patterns in genes such as MT2A, TFPI, MTND3, and HMGCS1 in the total RNA, as well as MT-TW, DNAJB1, and HSPB1 in the newly synthesized RNA, between the parental and drug-resistant groups. By applying pseudo-time analysis, we discovered that a specific cluster of cells exhibited characteristics of tumor stem cells. Furthermore, we observed a gradual decrease in the expression of ferroptosis-related molecules as drug resistance developed. In vitro experiments confirmed that the combination of a ferroptosis inducer called RSL3 effectively overcame drug resistance. In conclusion, this study revealed the resistance mechanism of selinexor in CML. In conclusion, we identified a subgroup of CML cells with tumor stem cell properties and demonstrated that ferroptosis inducer improved the efficacy of selinexor in overcoming drug resistance.
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Affiliation(s)
- Yunqi Cui
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Yating Li
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Jiamei Ji
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Na Hu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China; Department of Hematology, The Affiliated Suqian First People's Hospital of Nanjing Medical University, 120 Suzhi Road, Suqian 223812, Jiangsu, China
| | - Ke Min
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Wanting Ying
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Lei Fan
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China
| | - Ming Hong
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China.
| | - Jianyong Li
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China.
| | - Zhengxu Sun
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China.
| | - Xiaoyan Qu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu, China.
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3
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Saglio G, Yassin M, Alhuraiji A, Lal A, Alam A, Khan F, Khadada F, Osman H, Elkonaissi I, Marashi M, Abuhaleeqa M, Al-Khabori M, Pandita R, Al-Kindi S, Bahzad S, Daou D, Al Qudah Y. Current Status and Management of Chronic Myeloid Leukemia in the Gulf Region: Survey Results and Expert Opinion. Cancers (Basel) 2024; 16:2114. [PMID: 38893233 PMCID: PMC11172167 DOI: 10.3390/cancers16112114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/09/2024] [Accepted: 04/19/2024] [Indexed: 06/21/2024] Open
Abstract
Studies on chronic myeloid leukemia (CML) in the Gulf region are scarce, consisting of a survey and expert meeting that included 15 experts in 2023 which discussed CML diagnosis, testing, treatment objectives, toxicities, and discontinuation in the Gulf region. Most patients were reported to be in first-line therapy, and the most common treatments were imatinib/imatinib generic in first-line and dasatinib in second- and third-lines. Mutation analysis was not reported to be routinely performed at the time of diagnosis but rather in case of progression to accelerated/blast phase or any sign of loss of response. While all participants were aware that BCR-ABL should be monitored every three months during the first year of treatment, 10% reported monitoring BCR-ABL every six months in practice due to test cost and lab capability. The most important first-line therapy objective was "achievement of major molecular response" (MMR) in younger patients and "overall survival" in older ones. The most important treatment objectives were "MMR" and "early molecular response followed by prolongation of overall survival" in the short term and "treatment-free remission" in the long term. The current practices in CML in the Gulf region appear to be similar to global figures.
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Affiliation(s)
- Giuseppe Saglio
- Department of Hematology, University of Turin, 10124 Torino, Italy;
| | | | - Ahmad Alhuraiji
- Kuwait Cancer Control Center, Shuwaikh 1031, Kuwait; (A.A.); (R.P.); (S.B.)
| | - Amar Lal
- Tawam Hospital, Al Ain P.O. Box 5674, United Arab Emirates (A.A.); (H.O.)
| | - Arif Alam
- Tawam Hospital, Al Ain P.O. Box 5674, United Arab Emirates (A.A.); (H.O.)
| | - Faraz Khan
- American Hospital, Dubai P.O. Box 3050, United Arab Emirates;
| | - Fatima Khadada
- Kuwait Cancer Control Center, Shuwaikh 1031, Kuwait; (A.A.); (R.P.); (S.B.)
| | - Hani Osman
- Tawam Hospital, Al Ain P.O. Box 5674, United Arab Emirates (A.A.); (H.O.)
| | - Islam Elkonaissi
- Shaikh Shakhbout Medical City, Abu Dhabi P.O. Box 11001, United Arab Emirates;
| | | | | | - Murtadha Al-Khabori
- Department of Hematology, Sultan Qaboos University, Muscat 123, Oman; (M.A.-K.); (S.A.-K.)
| | - Ramesh Pandita
- Kuwait Cancer Control Center, Shuwaikh 1031, Kuwait; (A.A.); (R.P.); (S.B.)
| | - Salam Al-Kindi
- Department of Hematology, Sultan Qaboos University, Muscat 123, Oman; (M.A.-K.); (S.A.-K.)
| | - Shakir Bahzad
- Kuwait Cancer Control Center, Shuwaikh 1031, Kuwait; (A.A.); (R.P.); (S.B.)
| | - Dayane Daou
- Gulf, Novartis Pharma Services AG, 4056 Basel, Switzerland;
| | - Yasmin Al Qudah
- Oncology, Gulf, Novartis Pharma Services AG, 4056 Basel, Switzerland;
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4
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Okabe S, Moriyama M, Gotoh A. Combination of an aurora kinase inhibitor and the ABL tyrosine kinase inhibitor asciminib against ABL inhibitor-resistant CML cells. Med Oncol 2024; 41:142. [PMID: 38714583 PMCID: PMC11076330 DOI: 10.1007/s12032-024-02394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/24/2024] [Indexed: 05/10/2024]
Abstract
The development of BCR::ABL1-targeting tyrosine kinase inhibitors (TKIs) has improved the prognosis of patients with chronic myeloid leukemia (CML). However, resistance to ABL TKIs can develop in CML patients due to BCR::ABL1 point mutations and CML leukemia stem cell (LSC). Aurora kinases are essential kinases for cell division and regulate mitosis, especially the process of chromosomal segregation. Aurora kinase members also promote cancer cell survival and proliferation. This study analyzed whether aurora kinases were regulated in the progression of CML. It also evaluated the efficacy of the ABL TKI asciminib and the aurora kinase inhibitor LY3295668. The expressions of AURKA and AURKB were higher in the CML cells compared with normal cells using a public database (GSE100026). Asciminib or LY3295668 alone inhibited CML cells after 72 h, and cellular cytotoxicity was increased. The combined use of Asciminib and LY3295668 increased superior efficacy compared with either drug alone. Colony formation was reduced by cotreatment with asciminib and LY3295668. In the cell-cycle analyses, LY3295668 induced G2/M arrest. Cell populations in the sub-G1 phase were observed when cotreating with asciminib and LY3295668. The combination treatment also changed the mitochondrial membrane potential. In addition, AURKA shRNA transfectant cells had increased asciminib sensitivity. Combining asciminib and aurora kinase inhibition enhanced the efficacy and is proposed as a new therapeutic option for patients with CML. These findings have clinical implications for a potential novel therapeutic strategy for CML patients.
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MESH Headings
- Humans
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Apoptosis/drug effects
- Aurora Kinase A/antagonists & inhibitors
- Aurora Kinase B/antagonists & inhibitors
- Cell Line, Tumor
- Cell Proliferation/drug effects
- Drug Resistance, Neoplasm/drug effects
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Niacinamide/analogs & derivatives
- Pyrazoles
- Tyrosine Kinase Inhibitors/pharmacology
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Affiliation(s)
- Seiichi Okabe
- Department of Hematology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan.
| | - Mitsuru Moriyama
- Department of Hematology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Akihiko Gotoh
- Department of Hematology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
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5
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Young AL, Davis HC, Challen GA. Droplet Digital PCR for Oncogenic KMT2A Fusion Detection. J Mol Diagn 2023; 25:898-906. [PMID: 37813299 PMCID: PMC10851777 DOI: 10.1016/j.jmoldx.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023] Open
Abstract
Acute myeloid leukemia (AML) is an aggressive blood cancer diagnosed in approximately 120,000 individuals worldwide each year. During treatment for AML, detecting residual disease is essential for prognostication and treatment decision-making. Currently, methods for detecting residual AML are limited to identifying approximately 1:100 to 1:1000 leukemic cells (morphology and DNA sequencing) or are difficult to implement (flow cytometry). AML arising after chemotherapy or radiation exposure is termed therapy-related AML (t-AML) and is exceptionally aggressive and treatment resistant. t-AML is often driven by oncogenic fusions that result from prior treatments that introduce double-strand DNA breaks. The most common t-AML-associated translocations affect KMT2A. There are at least 80 known KMT2A fusion partners, but approximately 80% of fusions involve only five partners-AF9, AF6, AF4, ELL, and ENL. We present a novel droplet digital PCR assay targeting the most common KMT2A-rearrangements to enable detection of rare AML cells harboring these fusions. This assay was benchmarked in cell lines and patient samples harboring oncogenic KMT2A fusions and demonstrated a limit of detection of approximately 1:1,000,000 cells. Future application of this assay could improve disease detection and treatment decision-making for patients with t-AML with KMT2A fusions and premalignant oncogenic fusion detection in at-risk individuals after chemotherapy exposure.
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Affiliation(s)
- Andrew L Young
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Hannah C Davis
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Grant A Challen
- Division of Oncology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
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6
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Bewersdorf JP, How J, Masarova L, Bose P, Pemmaraju N, Mascarenhas J, Rampal RK. Moving toward disease modification in polycythemia vera. Blood 2023; 142:1859-1870. [PMID: 37729609 DOI: 10.1182/blood.2023021503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023] Open
Abstract
Polycythemia vera (PV) belongs to the BCR-ABL1-negative myeloproliferative neoplasms and is characterized by activating mutations in JAK2 and clinically presents with erythrocytosis, variable degrees of systemic and vasomotor symptoms, and an increased risk of both thromboembolic events and progression to myelofibrosis and acute myeloid leukemia (AML). Treatment selection is based on a patient's age and a history of thrombosis in patients with low-risk PV treated with therapeutic phlebotomy and aspirin alone, whereas cytoreductive therapy with either hydroxyurea or interferon alfa (IFN-α) is added for high-risk disease. However, other disease features such as significant disease-related symptoms and splenomegaly, concurrent thrombocytosis and leukocytosis, or intolerance of phlebotomy can constitute an indication for cytoreductive therapy in patients with otherwise low-risk disease. Additionally, recent studies demonstrating the safety and efficacy (ie, reduction in phlebotomy requirements and molecular responses) of ropegylated IFN-α2b support its use for patients with low-risk PV. Additionally, emerging data suggest that early treatment is associated with higher rates of molecular responses, which might eventually enable time-limited therapy. Nonetheless, longer follow-up is needed to assess whether molecular responses associate with clinically meaningful outcome measures such as thrombosis and progression to myelofibrosis or AML. In this article, we provide an overview of the current and evolving treatment landscape of PV and outline our vision for a patient-centered, phlebotomy-free, treatment approach using time-limited, disease-modifying treatment modalities early in the disease course, which could ultimately affect the natural history of the disease.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joan How
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Mascarenhas
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Raajit K Rampal
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
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7
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Zhang M, Lang X, Chen X, Lv Y. Prospective Identification of Prognostic Hot-Spot Mutant Gene Signatures for Leukemia: A Computational Study Based on Integrative Analysis of TCGA and cBioPortal Data. Mol Biotechnol 2023; 65:1898-1912. [PMID: 36879146 DOI: 10.1007/s12033-023-00704-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
The advantage of an increasing amount of bioinformatics data on leukemias intrigued us to explore the hot-spot mutation profiles and investigate the implications of those hot-spot mutations in patient survival. We retrieved somatic mutations and their distribution in protein domains through data analysis of The Cancer Genome Atlas and cBioPortal databases. After determining differentially expressed mutant genes related to leukemia, we further conducted principal component analysis and single-factor Cox regression analyses. Moreover, survival analysis was performed for the obtained candidate genes, followed by a multi-factor Cox proportional hazard model method for the impacts of the candidate genes on the survival and prognosis of patients with leukemia. At last, the signaling pathways involved in leukemia were investigated by gene set enrichment analysis. There were 223 somatic missense mutation hot-spots identified with pertinence to leukemia, which were distributed in 41 genes. Differential expression in leukemia was witnessed in 39 genes. We found a close correlation between seven genes and the prognosis of leukemia patients, among which, three genes could significantly influence the survival rate. In addition, among these three genes, CD74 and P2RY8 were highlighted due to close pertinence with survival conditions of leukemia patients. Finally, data suggested that B cell receptor, Hedgehog, and TGF-beta signaling pathways were enriched in low-hazard patients. In conclusion, these data underline the involvement of hot-spot mutations of CD74 and P2RY8 genes in survival status of leukemia patients, highlighting their as novel therapeutic targets or prognostic indicators for leukemia patients. Summary of Graphical Abstract: We identified 223 leukemia-associated somatic missense mutation hotspots concentrated in 41 different genes from 2297 leukemia patients in the TCGA database. Differential analysis of leukemic and normal samples from the TCGA and GTEx databases revealed that 39 of these 41 genes showed significant differential expression in leukemia. These 39 genes were subjected to PCA analysis, univariate Cox analysis, survival analysis, multivariate Cox regression analysis, GSEA pathway enrichment analysis, and then the association with leukemia survival prognosis and related pathways were investigated.
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Affiliation(s)
- Min Zhang
- Department of Hematology, The First People's Hospital of Yongkang, Affiliated to Hangzhou Medical College, No. 599, Jinshan West Road, Yongkang, Jinhua City, Zhejiang Province, 321300, People's Republic of China.
| | - Xianghua Lang
- Department of Hematology, The First People's Hospital of Yongkang, Affiliated to Hangzhou Medical College, No. 599, Jinshan West Road, Yongkang, Jinhua City, Zhejiang Province, 321300, People's Republic of China
| | - Xinyi Chen
- Department of Hematology, The First People's Hospital of Yongkang, Affiliated to Hangzhou Medical College, No. 599, Jinshan West Road, Yongkang, Jinhua City, Zhejiang Province, 321300, People's Republic of China
| | - Yuke Lv
- Department of Hematology, The First People's Hospital of Yongkang, Affiliated to Hangzhou Medical College, No. 599, Jinshan West Road, Yongkang, Jinhua City, Zhejiang Province, 321300, People's Republic of China
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8
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Zhang XS, Liu BC, Du X, Zhang YL, Xu N, Liu XL, Li WM, Lin H, Liang R, Chen CY, Huang J, Yang YF, Zhu HL, Pan L, Wang XD, Li GH, Liu ZG, Zhang YQ, Liu ZF, Hu JD, Liu CS, Li F, Yang W, Meng L, Han YQ, Lin LE, Zhao ZY, Tu CQ, Zheng CF, Bai YL, Zhou ZP, Chen SN, Qiu HY, Yang LJ, Sun XL, Sun H, Zhou L, Liu ZL, Wang DY, Guo JX, Pang LP, Zeng QS, Suo XH, Zhang WH, Zheng YJ, Jiang Q. [To compare the efficacy and incidence of severe hematological adverse events of flumatinib and imatinib in patients newly diagnosed with chronic phase chronic myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:728-736. [PMID: 38049316 PMCID: PMC10630575 DOI: 10.3760/cma.j.issn.0253-2727.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Indexed: 12/06/2023]
Abstract
Objective: To analyze and compare therapy responses, outcomes, and incidence of severe hematologic adverse events of flumatinib and imatinib in patients newly diagnosed with chronic phase chronic myeloid leukemia (CML) . Methods: Data of patients with chronic phase CML diagnosed between January 2006 and November 2022 from 76 centers, aged ≥18 years, and received initial flumatinib or imatinib therapy within 6 months after diagnosis in China were retrospectively interrogated. Propensity score matching (PSM) analysis was performed to reduce the bias of the initial TKI selection, and the therapy responses and outcomes of patients receiving initial flumatinib or imatinib therapy were compared. Results: A total of 4 833 adult patients with CML receiving initial imatinib (n=4 380) or flumatinib (n=453) therapy were included in the study. In the imatinib cohort, the median follow-up time was 54 [interquartile range (IQR), 31-85] months, and the 7-year cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) were 95.2%, 88.4%, 78.3%, and 63.0%, respectively. The 7-year FFS, PFS, and OS rates were 71.8%, 93.0%, and 96.9%, respectively. With the median follow-up of 18 (IQR, 13-25) months in the flumatinib cohort, the 2-year cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) were 95.4%, 86.5%, 58.4%, and 46.6%, respectively. The 2-year FFS, PFS, and OS rates were 80.1%, 95.0%, and 99.5%, respectively. The PSM analysis indicated that patients receiving initial flumatinib therapy had significantly higher cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) and higher probabilities of FFS than those receiving the initial imatinib therapy (all P<0.001), whereas the PFS (P=0.230) and OS (P=0.268) were comparable between the two cohorts. The incidence of severe hematologic adverse events (grade≥Ⅲ) was comparable in the two cohorts. Conclusion: Patients receiving initial flumatinib therapy had higher cumulative incidences of therapy responses and higher probability of FFS than those receiving initial imatinib therapy, whereas the incidence of severe hematologic adverse events was comparable between the two cohorts.
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Affiliation(s)
- X S Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - B C Liu
- National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - X Du
- The Second People's Hospital of Shenzhen, Shenzhen 518035, China
| | - Y L Zhang
- Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450008, China
| | - N Xu
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - X L Liu
- Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - W M Li
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - H Lin
- First Hospital of Jilin University, Changchun 130021, China
| | - R Liang
- Xijing Hospital, Airforce Military Medical University, Xi'an 710032, China
| | - C Y Chen
- Qilu Hospital of Shandong University, Jinan 250012, China
| | - J Huang
- The Fourth Affiliated Hospital of Zhejiang University, Hangzhou 322000, China
| | - Y F Yang
- Institute of Hematology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - H L Zhu
- Institute of Hematology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - L Pan
- Institute of Hematology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - X D Wang
- Sichuan Academy of Medical Sciences Sichuan Provincial People's Hospital, Chengdu 610072, China
| | - G H Li
- Xi'an International Medical Center Hospital, Xi'an 710038, China
| | - Z G Liu
- Shengjing Hospital of China Medical University, Shenyang 110020, China
| | - Y Q Zhang
- The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Z F Liu
- The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - J D Hu
- Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - C S Liu
- First Hospital of Jilin University, Changchun 130021, China
| | - F Li
- The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - W Yang
- Shengjing Hospital of China Medical University, Shenyang 110020, China
| | - L Meng
- Tongji Hospital of Tongji Medical College, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Y Q Han
- The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - L E Lin
- Hainan General Hospital, Haikou 570311, China
| | - Z Y Zhao
- Hainan General Hospital, Haikou 570311, China
| | - C Q Tu
- Shenzhen Baoan Hospital, Shenzhen University Second Affiliated Hospital, Shenzhen 518101, China
| | - C F Zheng
- Shenzhen Baoan Hospital, Shenzhen University Second Affiliated Hospital, Shenzhen 518101, China
| | - Y L Bai
- Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou 450003, China
| | - Z P Zhou
- The Second Hospital Affiliated to Kunming Medical University, Kunming 650106, China
| | - S N Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou 215006, China
| | - H Y Qiu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou 215006, China
| | - L J Yang
- Xi'an International Medical Center Hospital, Xi'an 710117, China
| | - X L Sun
- The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - H Sun
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - L Zhou
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Z L Liu
- Huazhong University of Science and Technology Union Shenzhen Hospital, Nanshan Hospital, Shenzhen 518000, China
| | - D Y Wang
- Huazhong University of Science and Technology Union Shenzhen Hospital, Nanshan Hospital, Shenzhen 518000, China
| | - J X Guo
- The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, China
| | - L P Pang
- Peking University Shenzhen Hospital, Shenzhen 516473, China
| | - Q S Zeng
- The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - X H Suo
- Handan Central Hospital, Handan 057150, China
| | - W H Zhang
- First Hospital of Shangxi Medical University, Taiyuan 300012, China
| | - Y J Zheng
- First Hospital of Shangxi Medical University, Taiyuan 300012, China
| | - Q Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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9
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Sun S, Qin J, Liao W, Gao X, Shang Z, Luo D, Xiong S. Mitochondrial Dysfunction in Cardiotoxicity Induced by BCR-ABL1 Tyrosine Kinase Inhibitors -Underlying Mechanisms, Detection, Potential Therapies. Cardiovasc Toxicol 2023; 23:233-254. [PMID: 37479951 DOI: 10.1007/s12012-023-09800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/08/2023] [Indexed: 07/23/2023]
Abstract
The advent of BCR-ABL tyrosine kinase inhibitors (TKIs) targeted therapy revolutionized the treatment of chronic myeloid leukemia (CML) patients. Mitochondria are the key organelles for the maintenance of myocardial tissue homeostasis. However, cardiotoxicity associated with BCR-ABL1 TKIs can directly or indirectly cause mitochondrial damage and dysfunction, playing a pivotal role in cardiomyocytes homeostatic system and putting the cancer survivors at higher risk. In this review, we summarize the cardiotoxicity caused by BCR-ABL1 TKIs and the underlying mechanisms, which contribute dominantly to the damage of mitochondrial structure and dysfunction: endoplasmic reticulum (ER) stress, mitochondrial stress, damage of myocardial cell mitochondrial respiratory chain, increased production of mitochondrial reactive oxygen species (ROS), and other kinases and other potential mechanisms of cardiotoxicity induced by BCR-ABL1 TKIs. Furthermore, detection and management of BCR-ABL1 TKIs will promote our rational use, and cardioprotection strategies based on mitochondria will improve our understanding of the cardiotoxicity from a mitochondrial perspective. Ultimately, we hope shed light on clinical decision-making. By integrate and learn from both research and practice, we will endeavor to minimize the mitochondria-mediated cardiotoxicity and reduce the adverse sequelae associated with BCR-ABL1 TKIs.
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Affiliation(s)
- Sheng Sun
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Department of Medical Oncology, Hospital of Chengdu University of Traditioanal Chinese Medicine, Chengdu, 610075, Sichuan Province, China
| | - Jiqiu Qin
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wenhao Liao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiang Gao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhoubiao Shang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dehua Luo
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shaoquan Xiong
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
- Department of Medical Oncology, Hospital of Chengdu University of Traditioanal Chinese Medicine, Chengdu, 610075, Sichuan Province, China.
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10
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Blanco Sánchez A, Gil Manso R, Carreño-Tarragona G, Paredes Ruiz D, González Olmedo J, Martínez-López J, Díaz Pedroche C, Ayala R. Multidisciplinary management in chronic myeloid leukemia improves cardiovascular risk measured by SCORE. Front Pharmacol 2023; 14:1206893. [PMID: 37538175 PMCID: PMC10394626 DOI: 10.3389/fphar.2023.1206893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction: Cardiovascular events are one of the main long-term complications in patients with chronic myeloid leukemia (CML) receiving treatment with tyrosine kinase inhibitors (TKIs). The proper choice of TKI and the adequate management of risk factors may reduce cardiovascular comorbidity in this population. Methods: This study evaluated the cardiovascular risk of a cohort of patients with CML at diagnosis and after follow-up in a specialized cardiovascular risk consultation. In order to do this, we performed data analysis from 35 patients who received TKIs and were referred to the aforementioned consultation between 2015 and 2018 at our center. Cardiovascular risk factors were analyzed separately, as well as integrated into the cardiovascular SCORE, both at diagnosis and at the last visit to the specialized consultation. Results: At the time of diagnosis, 60% had some type of risk factor, 20% had a high or very high risk SCORE, 40% had an intermediate risk, and 40% belonged to the low risk category. During follow-up, the main cardiovascular adverse event observed was hypertension (diagnosed in 8 patients, 23%). 66% of patients quit smoking, achieving control of blood pressure in 95%, diabetes in 50%, weight in 76%, and dyslipidemia in 92%. 5.7% of patients suffered a thrombotic event and a significant percentage of patients showed a reduction in their SCORE. Conclusion: Our study shows the benefit of controlling cardiovascular risk factors through follow-up in a specialized consultation for patients with CML treated with TKI.
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Affiliation(s)
| | - Rodrigo Gil Manso
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Diana Paredes Ruiz
- Department of Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Rosa Ayala
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
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11
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Abstract
The FGF receptors (FGFRs) belong to a family of receptor tyrosine kinases. Abundant evidence shows that FGFRs are closely related to tumor cell invasion and angiogenesis. Hence, targeted modulation of FGFRs has become an effective strategy for cancer treatment. Recently, the development of small-molecule inhibitors targeting FGFRs has been extensively studied, and three inhibitors have been approved for marketing. Based on the clinical problems with the current inhibitors, there is a need to develop novel inhibitors and technologies to address the pitfalls. This review summarizes recent advances in small-molecule inhibitors targeting FGFRs, focusing on structure-activity relationships. Moreover, recent progress of novel technologies are summarized to provide a reference for promoting the application of drugs targeting FGFRs in tumor therapy.
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12
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Lin Z, Wu Y, Xu Y, Li G, Li Z, Liu T. Mesenchymal stem cell-derived exosomes in cancer therapy resistance: recent advances and therapeutic potential. Mol Cancer 2022; 21:179. [PMID: 36100944 PMCID: PMC9468526 DOI: 10.1186/s12943-022-01650-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/30/2022] [Indexed: 12/12/2022] Open
Abstract
Mesenchymal stem cells (MSCs) are multipotent stromal cells that can be obtained from various human tissues and organs. They can differentiate into a wide range of cell types, including osteoblasts, adipocytes and chondrocytes, thus exhibiting great potential in regenerative medicine. Numerous studies have indicated that MSCs play critical roles in cancer biology. The crosstalk between tumour cells and MSCs has been found to regulate many tumour behaviours, such as proliferation, metastasis and epithelial-mesenchymal transition (EMT). Multiple lines of evidence have demonstrated that MSCs can secrete exosomes that can modulate the tumour microenvironment and play important roles in tumour development. Notably, very recent works have shown that mesenchymal stem cell-derived exosomes (MSC-derived exosomes) are critically involved in cancer resistance to chemotherapy agents, targeted-therapy drugs, radiotherapy and immunotherapy. In this review, we systematically summarized the emerging roles and detailed molecular mechanisms of MSC-derived exosomes in mediating cancer therapy resistance, thus providing novel insights into the clinical applications of MSC-derived exosomes in cancer management.
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13
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Karantanou C, Minciacchi VR, Karantanos T. Extracellular Vesicles in Myeloid Neoplasms. Int J Mol Sci 2022; 23:ijms23158827. [PMID: 35955960 PMCID: PMC9369333 DOI: 10.3390/ijms23158827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/26/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
Myeloid neoplasms arise from malignant primitive cells, which exhibit growth advantage within the bone marrow microenvironment (BMM). The interaction between these malignant cells and BMM cells is critical for the progression of these diseases. Extracellular vesicles (EVs) are lipid bound vesicles secreted into the extracellular space and involved in intercellular communication. Recent studies have described RNA and protein alterations in EVs isolated from myeloid neoplasm patients compared to healthy controls. The altered expression of various micro-RNAs is the best-described feature of EVs of these patients. Some of these micro-RNAs induce growth-related pathways such as AKT/mTOR and promote the acquisition of stem cell-like features by malignant cells. Another well-described characteristic of EVs in myeloid neoplasms is their ability to suppress healthy hematopoiesis either via direct effect on healthy CD34+ cells or via alteration of the differentiation of BMM cells. These results support a role of EVs in the pathogenesis of myeloid neoplasms. mainly through mediating the interaction between malignant and BMM cells, and warrant further study to better understand their biology. In this review, we describe the reported alterations of EV composition in myeloid neoplasms and the recent discoveries supporting their involvement in the development and progression of these diseases.
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Affiliation(s)
- Christina Karantanou
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, 60596 Frankfurt am Main, Germany
| | - Valentina René Minciacchi
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, 60596 Frankfurt am Main, Germany
| | - Theodoros Karantanos
- Division of Hematologic Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21218, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, The Bunting-Blaustein Cancer Research Building, 1650 Orleans Street, Baltimore, MD 21218, USA
- Correspondence:
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14
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Predictive scoring systems for molecular responses in persons with chronic phase chronic myeloid leukemia receiving initial imatinib therapy. Leukemia 2022; 36:2042-2049. [PMID: 35650426 DOI: 10.1038/s41375-022-01616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/09/2022]
Abstract
It is vital for physicians and persons with chronic myeloid leukemia (CML) to accurately predict the likelihood of achieving a major molecular response (MMR) and a deep molecular response (DMR; at least MR4) at the start of imatinib-therapy, which could help in decision making of treatment goals and strategies. To answer this question, we interrogated data from 1369 consecutive subjects with chronic phase CML receiving initial imatinib-therapy to identify predictive co-variates. Subjects were randomly-assigned to training (n = 913) and validation (n = 456) datasets. Male sex, higher WBC concentration, lower haemoglobin concentration, higher percentage blood blasts and larger spleen size were significantly-associated with lower cumulative incidences of MMR and MR4 in training dataset. Using Fine-Gray model, we developed the predictive scoring systems for MMR and MR4 which classified subjects into the low-, intermediate- and high-risk cohorts with significantly-different cumulative incidences of MMR and MR4 with good predictive discrimination and accuracy in training and validation cohorts with high area under the receiver-operator characteristic curve (AUROC) values. These data may help physicians decide appropriateness of initial imatinib therapy.
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15
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A predictive scoring system for therapy-failure in persons with chronic myeloid leukemia receiving initial imatinib therapy. Leukemia 2022; 36:1336-1342. [PMID: 35194158 DOI: 10.1038/s41375-022-01527-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/25/2022] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
Data from 1,364 consecutive subjects with chronic-phase chronic myeloid leukemia (CML) receiving initial imatinib-therapy were interrogated to identify co-variates predicting therapy failure. Subjects were randomly divided into training (n = 908) and validation datasets (n = 456). In the training dataset, WBC count ≥120 × 10E + 9/L, haemoglobin concentration <115 g/L, blood basophils ≥12% and European Treatment and Outcome Study for CML Long-Term Survival (ELTS) risk score were significantly-associated with failure-free survival (FFS). Each co-variate was assigned 1 point to develop the imatinib-therapy failure (IMTF) model except ELTS high-risk category which was assigned 2 points based on multi-variable regression coefficients. Area under receiver-operator characteristic curve values in the IMTF model for 1-, 3- and 5-year FFS were 0.79-0.84 in the training dataset and 0.78-0.85 in the validation dataset. Calibration plots showed high agreement between predicted and observed outcomes. Decision curve analyses indicated subjects benefited from clinical use of this model. Cumulative incidences of imatinib-therapy failure and probabilities of FFS among the 5 risk cohorts (very low-, low-, intermediate-, high- and very high-risk) using the IMTF model were significantly different (all p values < 0.001). The IMTF model also correlated with probabilities of progression-free survival and survival (all p values < 0.001). These data should help physicians optimize TKI-therapy strategy at diagnosis in persons with chronic phase CML.
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16
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Eskazan AE, Ali R, Alnıgeniş E, Ayyıldız O, Haznedaroğlu İ, Kırkızlar O, Kurtoğlu E, Malhan S, Öksüz E, Polat Ö, Saydam G, Sönmez M, Toprak SK, Toptaş T, Turgut M. Patient characteristics and management practices in chronic myeloid leukemia in Turkey: reflections from an expert meeting. Expert Rev Hematol 2022; 15:97-106. [DOI: 10.1080/17474086.2022.2044779] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ridvan Ali
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Ebru Alnıgeniş
- Department of Medical Affairs, Novartis Pharmaceuticals Corporation, Istanbul, Turkey
| | - Orhan Ayyıldız
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - İbrahim Haznedaroğlu
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Onur Kırkızlar
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Erdal Kurtoğlu
- Division of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Simten Malhan
- Department of Health Care Management, Faculty of Health Sciences, Başkent University, Ankara, Turkey
| | - Ergün Öksüz
- Department of Family Medicine, Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Özlem Polat
- Department of Medical Affairs, Novartis Pharmaceuticals Corporation, Istanbul, Turkey
| | - Güray Saydam
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Mehmet Sönmez
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Selami Koçak Toprak
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Tayfur Toptaş
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Mehmet Turgut
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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