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Bataller A, Bazinet A, DiNardo CD, Maiti A, Borthakur G, Daver NG, Short NJ, Jabbour EJ, Issa GC, Pemmaraju N, Yilmaz M, Montalban-Bravo G, Takahashi K, Loghavi S, Garcia-Manero G, Ravandi F, Kantarjian HM, Kadia TM. Prognostic risk signature in patients with acute myeloid leukemia treated with hypomethylating agents and venetoclax. Blood Adv 2024; 8:927-935. [PMID: 38113472 PMCID: PMC10877112 DOI: 10.1182/bloodadvances.2023011757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/30/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
ABSTRACT Hypomethylating agents (HMAs) and venetoclax (Ven) represent the standard of care for patients with acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. However, the European LeukemiaNet (ELN) risk classifications have been validated for patients treated with intensive therapy. In this study, we validate a recently proposed new molecular prognostic risk signature (mPRS) for patients with AML treated with HMAs and Ven. This classification allocated patients to favorable, intermediate (N/KRAS or FLT3-internal tandem duplication mutations), and lower (TP53 mutations) benefit groups. We retrospectively analyzed 159 patients treated with HMA and Ven. The mPRS classification allocated 74 (47%), 31 (19%), and 54 (34%) patients to the higher, intermediate, and lower-benefit groups, respectively. The overall response rate was 71% (86%, 54%, and 59% in the higher, intermediate, and lower-benefit groups, respectively). The median overall survival (OS) and event-free survival (EFS) times were 30 and 19 months, respectively, in the higher-benefit group; 12 and 8 months in the intermediate-benefit group; and 5 and 4 months in the lower-benefit group (P < .001). The C-index for OS and EFS was higher when stratifying patients according to mPRS classification than with the ELN 2022 classification. The 2-year cumulative incidence of relapse was 35%, 70%, and 60% in the higher, intermediate, and lower-benefit groups, respectively (P = .005). The mPRS classification accurately segregated groups of patients with AML treated with HMA plus Ven. In these patients, N/KRAS and TP53 mutations appear to negatively affect outcomes; therefore, new treatment approaches are warranted.
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Affiliation(s)
- Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Courtney D. DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval G. Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias J. Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ghayas C. Issa
- 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
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan M. Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Wachter F, Pikman Y. Pathophysiology of Acute Myeloid Leukemia. Acta Haematol 2024; 147:229-246. [PMID: 38228114 DOI: 10.1159/000536152] [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: 07/25/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a biologically heterogenous disease arising in clonally proliferating hematopoietic stem cells. Sequential acquisition of mutations leads to expanded proliferation of clonal myeloid progenitors and failure of differentiation, leading to fulminant AML. SUMMARY Here, we review the pathophysiology of AML with a focus on factors predisposing to AML development, including prior chemo- and radiation therapy, environmental factors, and germline predisposition. KEY MESSAGE Increasing genomic characterization of AML and insight into mechanisms of its development will be critical to improvement in AML prognostication and therapy.
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Affiliation(s)
- Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yana Pikman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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3
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Validation of the ALFA-1200 model in older patients with AML treated with intensive chemotherapy. Blood Adv 2023; 7:828-831. [PMID: 35405739 PMCID: PMC9996355 DOI: 10.1182/bloodadvances.2022007172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 01/18/2023] Open
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Wang B, Hua X, Zhang J, Gu W, Li H. Prognostication refinement in NPM1-mutated acute myeloid leukemia stratified by FLT3-ITD status with different induction doses of cytarabine. Cancer Med 2023; 12:9420-9433. [PMID: 36808479 PMCID: PMC10166952 DOI: 10.1002/cam4.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE We aimed to retrospectively discern the heterogeneity of outcomes from clinicopathological characteristics and next-generation sequencing (NGS) data in adult patients with NPM1-mutated (NPM1mut ) acute myeloid leukemia (AML) induced with standard-dose (SD, 100-200 mg/m2 ) and intermediate-dose (ID, 1000-2000 mg/m2 ) cytarabine arabinose (Ara-C). METHODS In the entire cohort and FLT3-ITD subgroups, multivariate Logistic and Cox regression analyses were used to analyze the comprehensive complete remission (cCR) rate after one or two induction cycles, event-free survival (EFS), and overall survival (OS). RESULTS Among a total of 203 NPM1mut patients evaluable for clinical outcome, 144 (70.9%) received a first SD-Ara-C induction and 59 (29.1%) received ID-Ara-C induction. Early death was recorded in seven (3.4%) after one or two cycles of induction. Focusing analysis on the NPM1mut /FLT3-ITD(-) subgroup, independent factors showing inferior outcome were presence of TET2 mutation [cCR rate, OR = 12.82 (95%CI 1.93-85.28), p = 0.008; EFS, HR = 2.92 (95%CI 1.46-5.86), p = 0.003], increasing age [EFS, HR = 1.49 (95%CI 1.10-2.02), p = 0.012 by every 10-years elevation], white blood cell count ≥60 × 109 /L [EFS, HR = 3.30 (95%CI 1.63-6.70), p = 0.001], and ≥4 mutated genes at initial diagnosis [OS, HR = 5.54 (95%CI 1.77-17.33), p = 0.003]. In contrast, when focusing on the NPM1mut /FLT3-ITD(+) subgroup, factors showing superior outcome were ID-Ara-C induction [cCR rate, OR = 0.20 (95%CI 0.05-0.81), p = 0.025; EFS, HR = 0.27 (95%CI 0.13-0.60), p = 0.001] and allo-transplantation [OS, HR = 0.45 (95%CI 0.21-0.94), p = 0.033]. Factors showing inferior outcome included CD34(+) [cCR rate, OR = 6.22 (95%CI 1.86-20.77), p = 0.003; EFS, HR = 2.01 (95%CI 1.12-3.61), p = 0.020] and ≥5 mutated genes [OS, HR = 2.85 (95%CI 1.33-6.10), p = 0.007]. CONCLUSION We conclude that TET2(+) , age, and white blood cell count convey an outcome risk modulation for AML with NPM1mut /FLT3-ITD(-) , as does CD34 and ID-Ara-C induction for NPM1mut /FLT3-ITD(+) . The findings permit re-stratification of NPM1mut AML into distinct prognostic subsets to guide risk-adapted individualized treatment.
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Affiliation(s)
- Biao Wang
- Department of Hematology, The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), Changzhou, China
| | - Xiaoying Hua
- Department of Hematology, The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), Changzhou, China
| | - Jihong Zhang
- Blood Research Laboratory, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weiying Gu
- Department of Hematology, The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), Changzhou, China
| | - Haiqian Li
- Department of Hematology, The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), Changzhou, China
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Bazinet A, Kantarjian HM. Moving toward individualized target-based therapies in acute myeloid leukemia. Ann Oncol 2023; 34:141-151. [PMID: 36423744 DOI: 10.1016/j.annonc.2022.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease at the genetic level. The field of AML therapy is increasingly shifting away from uniform approaches based solely on intensive chemotherapy (such as '7 + 3') toward personalized therapy. The treatment of AML can now be individualized based on patient characteristics and cytogenetic/molecular disease features. In this review, we provide a comprehensive updated summary of personalized, target-directed therapy in AML. We first discuss the selection of intensive versus low-intensity treatment approaches based on the patient's age and/or comorbidities. We follow with a detailed review of specific molecularly defined AML subtypes that benefit from the addition of targeted agents. In this context, we highlight the urgent need for novel therapies in tumor protein p53 (TP53)-mutated AML. We then propose approaches to optimize AML therapy in patients without directly actionable mutations. We conclude with a discussion on the emerging role of using measurable residual disease to modify therapy based on the quality of response.
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Affiliation(s)
- A Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - H M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA.
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6
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Rivera D, Kim K, Kanagal-Shamanna R, Borthakur G, Montalban-Bravo G, Daver N, Dinardo C, Short NJ, Yilmaz M, Pemmaraju N, Takahashi K, Jabbour EJ, Pierce S, Konopleva M, Bhalla K, Garcia-Manero G, Ravandi F, Kantarjian H, Kadia TM. Implications of RAS mutational status in subsets of patients with newly diagnosed acute myeloid leukemia across therapy subtypes. Am J Hematol 2022; 97:1599-1606. [PMID: 36117258 DOI: 10.1002/ajh.26731] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 01/31/2023]
Abstract
Activating mutations in RAS have been reported in about 10-15% of patients with AML; previous studies have not identified a prognostic significance. However, RAS mutations have emerged as a potential resistance mechanism to treatment with inhibitors of FLT3, IDH, and BCL2. We aimed to determine the characteristics and outcomes of patients with RAS-mutated (RAS-mut) AML across therapy subsets of 1410 patients newly diagnosed (ND AML). RAS-mut was observed in 273 (20%) patients. Overall, patients with RAS-mut AML had an estimated 3-year survival rate of 38% vs. 28% in those with RAS wild type (RAS-wt), p = .01. Among patients with RAS-mut, favorable karyotype and concomitant NPM1 mutations were associated with a higher CR/CRi rate, OR 23.2 (95% CI: 2.7-192.7; p < .001) and OR 2.8 (95% CI: 1.1-6.9; p = .02), respectively, while secondary and treated secondary (ts)-AML were associated with low response rates, OR 0.34 (95% CI: 0.1-0.9; p = .04) and OR 0.22 (95% CI: 0.09-0.5; p = .001), respectively. Intensive chemotherapy was associated with high response rates OR 5.9 (95% CI: 2.9-12.2; p < .001). Better median OS was observed among those with favorable karyotype, HR 0.28 (95% CI: 0.1-0.6; p = .002), and those treated with intensive chemotherapy, HR 0.42 (95% CI: 0.2-0.6 p < .001). Conversely, ts- AML and co-occurrence of mutations in TP53 were associated with poor median OS; HR 2.3 (95% CI: 1.4-3.9; p = .001) and HR 1.7 (95% CI: 0.9-3.1; p = .06), respectively. The addition of venetoclax was associated with a non-significant improvement in CR/CRi and OS.
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Affiliation(s)
- Daniel Rivera
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kunhwa Kim
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney Dinardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kapil Bhalla
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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7
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Intensified cytarabine dose during consolidation in adult AML patients under 65 years is not associated with survival benefit: real-world data from the German SAL-AML registry. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04356-9. [PMID: 36167894 PMCID: PMC10349710 DOI: 10.1007/s00432-022-04356-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Higher doses of cytarabine appear to improve long-term outcome in acute myeloid leukemia (AML), in particular for younger patients. To this end, the optimal dosage of single-agent cytarabine in consolidation therapy remains elusive. Here, we assessed the impact of different dosages of cytarabine consolidation after 7 + 3 induction on outcome in a large real-world data set from the German Study Alliance Leukemia-Acute Myeloid Leukemia (SAL-AML) registry. METHODS Patients between 18 and 64 years of age, registered between April 2005 and September 2020, who attained complete remission after intensive induction and received at least one consolidation cycle with intermediate (IDAC) or high-dose cytarabine (HiDAC) were selected. To account for differences in patient and disease characteristics between both groups, the average treatment effect was estimated by propensity score weighting. RESULTS Six-hundred-forty-two patients received HiDAC consolidation with median dosage of 17.6 (IQR (interquartile range), 16.5-18.0) g/m2 for a median number of 3 cycles (IQR, 2-3), whereas 178 patients received IDAC consolidation with 5.9 (IQR, 5.7-8.6) g/m2 for a median of 2 cycles (IQR, 1-3). Both groups differed significantly in some important characteristics (age, sex, cytogenetic risk group, ECOG performance status, disease status, HCT-CI, number of induction cycles). After propensity score weighting for differences in patient and disease characteristics, relapse-free survival after 2 years was comparable between HiDAC-treated (55.3%) and IDAC-treated (55.6%) patients (HR = 0.935, p = 0.69). Moreover, no significant differences in overall survival were observed after 2 years (84.7 vs. 80.6%, HR = 1.101, p = 0.65). Notably, more patients treated with IDAC received allogeneic hematopoietic cell transplantation in first remission (37.6 vs. 19.8%, p < 0.001). Censoring for allogeneic hematopoietic cell transplantation in first remission revealed no significant survival difference with regard to cytarabine dosage. Considering only of European LeukemiaNet (ELN) favorable-risk AML patients, there was no significant difference in outcome. Of note, significantly more patients treated with HiDAC suffered from ≥ 3 CTCAE infectious complications (56.7 [95%-CI 52.8-60.6%] vs. 44.1% [95%-CI 36.6-51.7%]; p = 0,004). The rate of other ≥ 3 CTCAE non-hematological toxicities and secondary malignancies was comparable in both treatment groups. CONCLUSIONS This retrospective analysis suggests no significant benefit of high-dose cytarabine compared to intermediate dosages in consolidation for AML patients under 65 years of age, independent of ELN risk group. TRIAL REGISTRATION NCT03188874.
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Wang H, He X, Zhang L, Dong H, Huang F, Xian J, Li M, Chen W, Lu X, Pathak KV, Huang W, Li Z, Zhang L, Nguyen LXT, Yang L, Feng L, Gordon DJ, Zhang J, Pirrotte P, Chen CW, Salhotra A, Kuo YH, Horne D, Marcucci G, Sykes DB, Tiziani S, Jin H, Wang X, Li L. Disruption of dNTP homeostasis by ribonucleotide reductase hyperactivation overcomes AML differentiation blockade. Blood 2022; 139:3752-3770. [PMID: 35439288 PMCID: PMC9247363 DOI: 10.1182/blood.2021015108] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/07/2022] [Indexed: 01/09/2023] Open
Abstract
Differentiation blockade is a hallmark of acute myeloid leukemia (AML). A strategy to overcome such a blockade is a promising approach against the disease. The lack of understanding of the underlying mechanisms hampers development of such strategies. Dysregulated ribonucleotide reductase (RNR) is considered a druggable target in proliferative cancers susceptible to deoxynucleoside triphosphate (dNTP) depletion. Herein, we report an unanticipated discovery that hyperactivating RNR enables differentiation and decreases leukemia cell growth. We integrate pharmacogenomics and metabolomics analyses to identify that pharmacologically (eg, nelarabine) or genetically upregulating RNR subunit M2 (RRM2) creates a dNTP pool imbalance and overcomes differentiation arrest. Moreover, R-loop-mediated DNA replication stress signaling is responsible for RRM2 activation by nelarabine treatment. Further aggravating dNTP imbalance by depleting the dNTP hydrolase SAM domain and HD domain-containing protein 1 (SAMHD1) enhances ablation of leukemia stem cells by RRM2 hyperactivation. Mechanistically, excessive activation of extracellular signal-regulated kinase (ERK) signaling downstream of the imbalance contributes to cellular outcomes of RNR hyperactivation. A CRISPR screen identifies a synthetic lethal interaction between loss of DUSP6, an ERK-negative regulator, and nelarabine treatment. These data demonstrate that dNTP homeostasis governs leukemia maintenance, and a combination of DUSP inhibition and nelarabine represents a therapeutic strategy.
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Affiliation(s)
- Hanying Wang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
- Department of Medical Oncology and
| | - Xin He
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Lei Zhang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Haojie Dong
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Feiteng Huang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jie Xian
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Min Li
- Department of Information Sciences, Beckman Research Institute and
| | - Wei Chen
- Integrative Genomics Core, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Xiyuan Lu
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, TX
| | - Khyatiben V Pathak
- Cancer & Cell Biology Division, The Translational Genomics Research Institute, Phoenix, AZ
| | - Wenfeng Huang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Zheng Li
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lianjun Zhang
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Le Xuan Truong Nguyen
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Lu Yang
- Department of Systems Biology, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - Lifeng Feng
- Laboratory of Cancer Biology, Provincial Key Laboratory of Biotherapy in Zhejiang, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - David J Gordon
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Jing Zhang
- McArdle Laboratory for Cancer Research and Wisconsin Blood Cancer Research Institute, University of Wisconsin-Madison, Madison, WI
| | - Patrick Pirrotte
- Cancer & Cell Biology Division, The Translational Genomics Research Institute, Phoenix, AZ
- Cancer & Cell Biology Division, The Translational Genomics Research Institute, Phoenix, AZ
| | - Chun-Wei Chen
- Department of Systems Biology, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | | | - Ya-Huei Kuo
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
| | - David Horne
- Department of Molecular Medicine, Beckman Research Institute of City of Hope, Duarte, CA
| | - Guido Marcucci
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
- Department of Hematology and Hematopoietic Cell Transplantation and
| | - David B Sykes
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA; and
| | - Stefano Tiziani
- Department of Nutritional Sciences, The University of Texas at Austin, Austin, TX
- Department of Pediatrics and
- Department of Oncology, Dell Medical School, LiveSTRONG Cancer Institutes, The University of Texas at Austin, Austin, TX
| | - Hongchuan Jin
- Laboratory of Cancer Biology, Provincial Key Laboratory of Biotherapy in Zhejiang, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | | | - Ling Li
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope Medical Center, Duarte, CA
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9
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Desikan SP, Ravandi F, Pemmaraju N, Konopleva M, Loghavi S, Jabbour EJ, Daver N, Jain N, Chien KS, Maiti A, Montalban-Bravo G, Kadia TM, Macaron W, DeLumpa R, Kwari M, Borthakur G, Short NJ. A Phase II Study of Azacitidine, Venetoclax and Trametinib in Relapsed or Refractory AML Harboring RAS Pathway-Activating Mutations. Acta Haematol 2022; 145:529-536. [PMID: 35717939 DOI: 10.1159/000525566] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/14/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION RAS pathway mutations are common mechanisms of resistance to acute myeloid leukemia (AML) therapies. Trametinib, an oral MEK inhibitor, has been shown to have single-agent activity in relapsed/refractory AML and preclinical synergy with venetoclax. METHODS We conducted a single-center, open-label, phase 2 trial of the combination of azacitidine, venetoclax, and trametinib in patients with relapsed or refractory AML harboring a RAS pathway-activating mutation. RESULTS Sixteen patients were treated. The patients were heavily pretreated with a median number of 4 prior therapies; 13 (81%) had received prior hypomethylating agent (HMA) with venetoclax and 8 (50%) had undergone prior stem cell transplant. Four patients (25%) responded (CR, n=1; CRi, n=1; MLFS, n=2). Two of the 3 patients (67%) who had not previously received HMA plus venetoclax responded; in contrast, only 2 of the 13 patients (15%) who had previously received HMA plus venetoclax responded. The median OS was 2.4 months, and the 6-month OS rate was 31%. Related grade 3-4 adverse events occurred in 50% of patients, and 50% of patients required a dose adjustment of trametinib. CONCLUSIONS The combination of azacitidine, venetoclax and trametinib had only modest activity in patients with relapsed/refractory AML, with a response rate that was similar to previous reports of trametinib monotherapy. Substantial toxicity was observed with this combination. Given the established role of RAS pathway mutations in mediating resistance to AML therapies, future studies of better tolerated, more active inhibitors of this pathway are still needed.
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Affiliation(s)
- Sai Prasad Desikan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly S Chien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abhishek Maiti
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Walid Macaron
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ricardo DeLumpa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Monica Kwari
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Raimondi V, Ciotti G, Gottardi M, Ciccarese F. 2-Hydroxyglutarate in Acute Myeloid Leukemia: A Journey from Pathogenesis to Therapies. Biomedicines 2022; 10:biomedicines10061359. [PMID: 35740380 PMCID: PMC9220225 DOI: 10.3390/biomedicines10061359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022] Open
Abstract
The oncometabolite 2-hydroxyglutarate (2-HG) plays a key role in differentiation blockade and metabolic reprogramming of cancer cells. Approximatively 20–30% of acute myeloid leukemia (AML) cases carry mutations in the isocitrate dehydrogenase (IDH) enzymes, leading to a reduction in the Krebs cycle intermediate α-ketoglutarate (α-KG) to 2-HG. Relapse and chemoresistance of AML blasts following initial good response to standard therapy account for the very poor outcome of this pathology, which represents a great challenge for hematologists. The decrease of 2-HG levels through pharmacological inhibition of mutated IDH enzymes induces the differentiation of AML blasts and sensitizes leukemic cells to several anticancer drugs. In this review, we provide an overview of the main genetic mutations in AML, with a focus on IDH mutants and the role of 2-HG in AML pathogenesis. Moreover, we discuss the impact of high levels of 2-HG on the response of AML cells to antileukemic therapies and recent evidence for highly efficient combinations of mutant IDH inhibitors with other drugs for the management of relapsed/refractory (R/R) AML.
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Affiliation(s)
- Vittoria Raimondi
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padova, Italy
- Correspondence:
| | - Giulia Ciotti
- Onco Hematology, Department of Oncology, Veneto Institute of Oncology IOV–IRCCS, 31033 Castelfranco Veneto, Italy; (G.C.); (M.G.)
| | - Michele Gottardi
- Onco Hematology, Department of Oncology, Veneto Institute of Oncology IOV–IRCCS, 31033 Castelfranco Veneto, Italy; (G.C.); (M.G.)
| | - Francesco Ciccarese
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV–IRCCS, 35128 Padova, Italy;
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11
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Shao R, Wang H, Liu W, Wang J, Lu S, Tang H, Lu Y. Establishment of a prognostic ferroptosis-related gene profile in acute myeloid leukaemia. J Cell Mol Med 2021; 25:10950-10960. [PMID: 34741393 PMCID: PMC8642683 DOI: 10.1111/jcmm.17013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/17/2022] Open
Abstract
Acute myeloid leukaemia (AML) is a heterogeneous disease with a difficult to predict prognosis. Ferroptosis, an iron‐induced programmed cell death, is a promising target for cancer therapy. Nevertheless, not much is known about the relationship between ferroptosis‐related genes and AML prognosis. Herein, we retrieved RNA profile and corresponding clinical data of AML patients from the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases. Univariate Cox analysis was employed to identify ferroptosis‐related genes significantly associated with AML prognosis. Next, the least absolute shrinkage and selection operator (LASSO) regression was employed to establish a prognostic ferroptosis‐related gene profile. 12 ferroptosis‐related genes were screened to generate a prognostic model, which stratified patients into a low‐ (LR) or high‐risk (HR) group. Using Kaplan‐Meier analysis, we demonstrated that the LR patients exhibited better prognosis than HR patients. Moreover, receiver operating characteristic (ROC) curve analysis confirmed that the prognostic model showed good predictability. Functional enrichment analysis indicated that the infiltration of regulatory T cells (Treg) differed vastly between the LR and HR groups. Our prognostic model can offer guidance into the accurate prediction of AML prognosis and selection of personalized therapy in clinical practice.
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Affiliation(s)
- Ruonan Shao
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Huizhong Wang
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wenjian Liu
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jingzi Wang
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shujing Lu
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hailin Tang
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yue Lu
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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12
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Dillon M, Lopez A, Lin E, Sales D, Perets R, Jain P. Progress on Ras/MAPK Signaling Research and Targeting in Blood and Solid Cancers. Cancers (Basel) 2021; 13:cancers13205059. [PMID: 34680208 PMCID: PMC8534156 DOI: 10.3390/cancers13205059] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary The Ras-Raf-MEK-ERK signaling pathway is responsible for regulating cell proliferation, differentiation, and survival. Overexpression and overactivation of members within the signaling cascade have been observed in many solid and blood cancers. Research often focuses on targeting the pathway to disrupt cancer initiation and progression. We aimed to provide an overview of the pathway’s physiologic role and regulation, interactions with other pathways involved in cancer development, and mutations that lead to malignancy. Several blood and solid cancers are analyzed to illustrate the impact of the pathway’s dysregulation, stemming from mutation or viral induction. Finally, we summarized different approaches to targeting the pathway and the associated novel treatments being researched or having recently achieved approval. Abstract The mitogen-activated protein kinase (MAPK) pathway, consisting of the Ras-Raf-MEK-ERK signaling cascade, regulates genes that control cellular development, differentiation, proliferation, and apoptosis. Within the cascade, multiple isoforms of Ras and Raf each display differences in functionality, efficiency, and, critically, oncogenic potential. According to the NCI, over 30% of all human cancers are driven by Ras genes. This dysfunctional signaling is implicated in a wide variety of leukemias and solid tumors, both with and without viral etiology. Due to the strong evidence of Ras-Raf involvement in tumorigenesis, many have attempted to target the cascade to treat these malignancies. Decades of unsuccessful experimentation had deemed Ras undruggable, but recently, the approval of Sotorasib as the first ever KRas inhibitor represents a monumental breakthrough. This advancement is not without novel challenges. As a G12C mutant-specific drug, it also represents the issue of drug target specificity within Ras pathway; not only do many drugs only affect single mutational profiles, with few pan-inhibitor exceptions, tumor genetic heterogeneity may give rise to drug-resistant profiles. Furthermore, significant challenges in targeting downstream Raf, especially the BRaf isoform, lie in the paradoxical activation of wild-type BRaf by BRaf mutant inhibitors. This literature review will delineate the mechanisms of Ras signaling in the MAPK pathway and its possible oncogenic mutations, illustrate how specific mutations affect the pathogenesis of specific cancers, and compare available and in-development treatments targeting the Ras pathway.
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13
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Kinowaki Y, Taguchi T, Onishi I, Kirimura S, Kitagawa M, Yamamoto K. Overview of Ferroptosis and Synthetic Lethality Strategies. Int J Mol Sci 2021; 22:9271. [PMID: 34502181 PMCID: PMC8430824 DOI: 10.3390/ijms22179271] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 12/31/2022] Open
Abstract
Ferroptosis, a term first proposed in 2012, is iron-dependent, non-apoptotic regulatory cell death induced by erastin. Ferroptosis was originally discovered during synthetic lethal screening for drugs sensitive to RAS mutant cells, and is closely related to synthetic lethality. Ferroptosis sensitizes cancer stem cells and tumors that undergo epithelial-mesenchymal transition and are resistant to anticancer drugs or targeted therapy. Therefore, ferroptosis-inducing molecules are attractive new research targets. In contrast, synthetic lethal strategies approach mechanisms and genetic abnormalities that cannot be directly targeted by conventional therapeutic strategies, such as RAS mutations, hypoxia, and abnormalities in the metabolic environment. They also target the environment and conditions specific to malignant cells, have a low toxicity to normal cells, and can be used in combination with known drugs to produce new ones. However, the concept of synthetic lethality has not been widely adopted with ferroptosis. In this review, we surveyed the literature on ferroptosis-related factors and synthetic lethality to examine the potential therapeutic targets in ferroptosis-related molecules, focusing on factors related to synthetic lethality, discovery methods, clinical application stages, and issues in drug discovery.
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Affiliation(s)
- Yuko Kinowaki
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (T.T.); (M.K.)
| | - Towako Taguchi
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (T.T.); (M.K.)
| | - Iichiroh Onishi
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (I.O.); (S.K.)
| | - Susumu Kirimura
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (I.O.); (S.K.)
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (T.T.); (M.K.)
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; (T.T.); (M.K.)
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14
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Bedair HM, Attia MH, Gohar SF, Khalaf FM, Badr El-DIN S, Rabie H. The prognostic impact of Wilms tumor-1 polymorphism (rs16754) and human myeloid inhibitory C-type lectin-like receptor expression in cytogenetically normal-acute myeloid leukemia. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2021. [DOI: 10.1186/s43042-021-00183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There are several genetic mutations that carry prognostic and predictive values in acute myeloid leukemia (AML). They are also implicated in disease pathogenesis and patient outcome. They can be a target of novel therapies for AML. The aim of the current study was to investigate prognostic value of Wilms’ tumor-1 (WT1) genotypes and human myeloid inhibitory C-type lectin-like (hMICL) receptor expression in normal-cytogenetic group of patients with AML. Genotyping of WT1 mutations was done by Rotor Gene real-time polymerase chain reaction (PCR) while hMICL expression was detected using phycoerythrin (PE)-conjugated mouse monoclonal anti-human (MoAbs) by flow cytometry.
Results
Sixty-three patients with cytogenetically normal AML (CN-AML) were included in the study. The alternate allele of WT1 single nucleotide polymorphism (SNP) rs16754 was found in 26.89%. At day 28 of therapy, complete remission was achieved in 100% of cases harboring mutant AG plus GG genotypes but only in 6.38% of cases harboring wild genotype (AA). After 6 months, 88.23% of patients harboring WT1 mutant genotype maintained complete remission, while only 23.40% of patients with wild type showed complete remission. The overall survival in patients harboring mutant WT1 genotypes was significantly longer than in those who carried the wild type gene (P-value, 0.001). Additionally, hMICL was overexpressed in approximately 87.3% of AML cases and inversely related to complete response. Similarly, overall survival was significantly shorter in patients with positive hMICL (P-value, 0.001).
Conclusion
Mutant WT1 genotypes (SNP rs16754) were conversely, associated with complete response, and hMICL overexpression had poor prognostic value in AML.
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15
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Ayala R, Rapado I, Onecha E, Martínez-Cuadrón D, Carreño-Tarragona G, Bergua JM, Vives S, Algarra JL, Tormo M, Martinez P, Serrano J, Herrera P, Ramos F, Salamero O, Lavilla E, Gil C, López Lorenzo JL, Vidriales MB, Labrador J, Falantes JF, Sayas MJ, Paiva B, Barragán E, Prosper F, Sanz MÁ, Martínez-López J, Montesinos P. The Mutational Landscape of Acute Myeloid Leukaemia Predicts Responses and Outcomes in Elderly Patients from the PETHEMA-FLUGAZA Phase 3 Clinical Trial. Cancers (Basel) 2021; 13:cancers13102458. [PMID: 34070172 PMCID: PMC8158477 DOI: 10.3390/cancers13102458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 12/30/2022] Open
Abstract
We sought to predict treatment responses and outcomes in older patients with newly diagnosed acute myeloid leukemia (AML) from our FLUGAZA phase III clinical trial (PETHEMA group) based on mutational status, comparing azacytidine (AZA) with fludarabine plus low-dose cytarabine (FLUGA). Mutational profiling using a custom 43-gene next-generation sequencing panel revealed differences in profiles between older and younger patients, and several prognostic markers that were useful in young patients were ineffective in older patients. We examined the associations between variables and overall responses at the end of the third cycle. Patients with mutated DNMT3A or EZH2 were shown to benefit from azacytidine in the treatment-adjusted subgroup analysis. An analysis of the associations with tumor burden using variant allele frequency (VAF) quantification showed that a higher overall response was associated with an increase in TET2 VAF (odds ratio (OR), 1.014; p = 0.030) and lower TP53 VAF (OR, 0.981; p = 0.003). In the treatment-adjusted multivariate survival analyses, only the NRAS (hazard ratio (HR), 1.9, p = 0.005) and TP53 (HR, 2.6, p = 9.8 × 10-7) variants were associated with shorter overall survival (OS), whereas only mutated BCOR (HR, 3.6, p = 0.0003) was associated with a shorter relapse-free survival (RFS). Subgroup analyses of OS according to biological and genomic characteristics showed that patients with low-intermediate cytogenetic risk (HR, 1.51, p = 0.045) and mutated NRAS (HR, 3.66, p = 0.047) benefited from azacytidine therapy. In the subgroup analyses, patients with mutated TP53 (HR, 4.71, p = 0.009) showed a better RFS in the azacytidine arm. In conclusion, differential mutational profiling might anticipate the outcomes of first-line treatment choices (AZA or FLUGA) in older patients with AML. The study is registered at ClinicalTrials.gov as NCT02319135.
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Affiliation(s)
- Rosa Ayala
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (I.R.); (E.O.); (G.C.-T.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
- Departament of Medicine, Complutense University, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Correspondence: (R.A.); (J.M.-L.)
| | - Inmaculada Rapado
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (I.R.); (E.O.); (G.C.-T.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
| | - Esther Onecha
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (I.R.); (E.O.); (G.C.-T.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
| | - David Martínez-Cuadrón
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Gonzalo Carreño-Tarragona
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (I.R.); (E.O.); (G.C.-T.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
| | - Juan Miguel Bergua
- Hematology Department, Hospital San Pedro Acantara, 10003 Cáceres, Spain;
| | - Susana Vives
- Department of Hematology, ICO Badalona-Hospital Germans Trias i Pujol. Josep Carreras Leukemia Research Institute. Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | | | - Mar Tormo
- Hematology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - Pilar Martinez
- Hematology Department, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Josefina Serrano
- Hematology Department, Hospital Universitario Reina Sofía, 14004 Cordoba, Spain;
| | - Pilar Herrera
- Hematology Department, Hospital Ramon y Cajal, 28034 Madrid, Spain;
| | - Fernando Ramos
- Hematology Department, Hospital Universitario de León, 24008 León, Spain;
| | - Olga Salamero
- Hematology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
| | - Esperanza Lavilla
- Hematology Department, Hospital Universitario Xeral de Lugo, 27003 Lugo, Spain;
| | - Cristina Gil
- Hematology Department, Hospital General de Alicante, 03010 Alicante, Spain;
| | | | - María Belén Vidriales
- Hematology Department, Hospital Universitario de Salamanca, IBSAL, 37007 Salamanca, Spain;
| | - Jorge Labrador
- Hematology Department, Hospital Universitario de Burgos, 09001 Burgos, Spain;
| | - José Francisco Falantes
- Hematology Department, Hospital Universitario Vírgen del Rocío, Instituto de BioMedicina de Sevilla, 41013 Sevilla, Spain;
| | - María José Sayas
- Hematology Department, Hospital Doctor Peset, 46017 Valencia, Spain;
| | - Bruno Paiva
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Hematology Department, Clínica Universitaria de Navarra, 31008 Navarra, Spain
| | - Eva Barragán
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Felipe Prosper
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Hematology Department, Clínica Universitaria de Navarra, 31008 Navarra, Spain
| | - Miguel Ángel Sanz
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Joaquín Martínez-López
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (I.R.); (E.O.); (G.C.-T.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
- Departament of Medicine, Complutense University, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Correspondence: (R.A.); (J.M.-L.)
| | - Pau Montesinos
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain; (B.P.); (E.B.); (F.P.); (M.Á.S.); (P.M.)
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
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16
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Akram AM, Chaudhary A, Kausar H, Althobaiti F, Abbas AS, Hussain Z, Fatima N, Zafar E, Asif W, Afzal U, Yousaf Z, Zafar A, Harakeh SM, Qamer S. Analysis of RAS gene mutations in cytogenetically normal de novo acute myeloid leukemia patients reveals some novel alterations. Saudi J Biol Sci 2021; 28:3735-3740. [PMID: 34220225 PMCID: PMC8241590 DOI: 10.1016/j.sjbs.2021.04.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 11/26/2022] Open
Abstract
Rat sarcoma gene (RAS) holds great importance in pathogenesis of acute myeloid leukemia (AML). The activated mutations in Neuroblastoma rat sarcoma viral oncogene homolog (NRAS) and Kirsten rat sarcoma viral oncogene homolog (KRAS) confers proliferative and survival signals, deliberating numerous effects on overall survival and progression free survival in AML patients. In this study thirty one (31) blood samples of adult newly diagnosed AML patients were collected to identify possible incidence of mutations through amplification of KRAS (exon 1 and 2) and NRAS gene (exon 1 and 2) using polymerase chain reaction (PCR). Amplicons were then subjected to sequencing and were analyzed through Geneious Prime 2019. Five of thirty one (16.12%) patients had altered sites in either NRAS or KRAS. The NRAS mutations were observed in three AML patients (N = 3, 9.67%). A novel missense mutation NRAS-I36R (239 T > G) representing a substitution of single nucleotide basepair found in NRAS exon 1 while exon 2 was detected with heterozygous mutation NRAS-E63X (318G > T) and insertion (A), resulting in frameshift of the amino acid sequence and insertion of two nucleotide basepairs (TA) in two of the patients. KRAS mutations (N = 2, 6.45%) were found in exon 1 whereas no mutations in KRAS exon 2 were detected in our patient cohort. Mutation in KRAS Exon 1, KRAS-D30N (280G > A) was observed in two patients and one of them also had a novel heterozygous mutation KRAS-L16N (240G > C). In addition there was no statistically significant association of mutRAS gene of AML patients with several prognostic markers including age, gender, karyotyping, CD34 positivity, cytogenetic abnormalities, total leukocyte count, white blood cell count and French-American-British (FAB) classification. However, the presence of mutRAS gene were strongly associated (p = 0.001) with increased percentage of bone marrow blasts. The prevalence of mutations in correlation with clinical and hematological parameter is useful for risk stratification in AML patients.
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Affiliation(s)
- Afia Muhammad Akram
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Asma Chaudhary
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Humera Kausar
- Department of Biotechnology, Kinnaird College for Women, Lahore, Pakistan
| | - Fayez Althobaiti
- Department of Biotechnology, College of Science, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Afshan Syed Abbas
- Department of Zoology, University of Education, Lower Mall Campus, Lahore, Pakistan
| | - Zawar Hussain
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Naz Fatima
- Molecular Biology Laboratory, Department of Zoology, University of the Punjab, Lahore, Pakistan
| | - Erum Zafar
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Wajiha Asif
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Umair Afzal
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Zoufishan Yousaf
- Department of Zoology, Division of Science and Technology, University of Education, Township, Lahore, Pakistan
| | - Amjad Zafar
- Department of Oncology, Mayo Hospital, Anarkali Bazar, Lahore, Pakistan
| | - Steve M Harakeh
- Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Samina Qamer
- Department of Zoology, Government College University, Faisalabad, Pakistan
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17
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Mustachio LM, Chelariu-Raicu A, Szekvolgyi L, Roszik J. Targeting KRAS in Cancer: Promising Therapeutic Strategies. Cancers (Basel) 2021; 13:1204. [PMID: 33801965 PMCID: PMC7999304 DOI: 10.3390/cancers13061204] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/05/2021] [Indexed: 12/17/2022] Open
Abstract
The Kirsten rat sarcoma viral oncogene homolog (KRAS) is mutated in approximately 25% of all human cancers and is known to be a major player promoting and maintaining tumorigenesis through the RAS/MAPK pathway. Over the years, a large number of studies have identified strategies at different regulatory levels to tackle this 'difficult-to-target' oncoprotein. Yet, the most ideal strategy to overcome KRAS and its downstream effects has yet to be uncovered. This review summarizes the role of KRAS activating mutations in multiple cancer types as well as the key findings for potential strategies inhibiting its oncogenic behavior. A comprehensive analysis of the different pathways and mechanisms associated with KRAS activity in tumors will ultimately pave the way for promising future work that will identify optimum therapeutic strategies.
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Affiliation(s)
- Lisa Maria Mustachio
- Department of Epigenetics and Molecular Carcinogenesis, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Center for Cancer Epigenetics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Anca Chelariu-Raicu
- Department of Obstetrics and Gynecology, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany;
| | - Lorant Szekvolgyi
- Genome Architecture and Recombination Research Group, Department of Biochemistry and Molecular Biology, MTA-DE Momentum, Faculty of Medicine, University of Debrecen, 4002 Debrecen, Hungary;
| | - Jason Roszik
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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18
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Wang B, Yang B, Ling Y, Zhang J, Hua X, Gu W, Yan F. Role of CD19 and specific KIT-D816 on risk stratification refinement in t(8;21) acute myeloid leukemia induced with different cytarabine intensities. Cancer Med 2020; 10:1091-1102. [PMID: 33382538 PMCID: PMC7897948 DOI: 10.1002/cam4.3705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/22/2020] [Accepted: 12/07/2020] [Indexed: 12/23/2022] Open
Abstract
High‐dose cytarabine (Ara‐C) has been reported with increased treatment‐related mortality, whereas few data are available concerning intermediate‐dose Ara‐C for induction of acute myeloid leukemia (AML) with t(8;21) translocation. We retrospectively analyzed factors impacting complete remission (CR), event‐free survival (EFS), cumulative incidence of relapse (CIR), and overall survival (OS) in 197 adults with t(8;21) AML, of whom 107 cases were induced with intermediate‐dose and 90 with standard‐dose Ara‐C (as part of 3 + 7 protocol). After a single induction course, the overall CR rate was 87.6% (170/194), with a significant difference between the standard‐dose (83/105, 79.0%) and intermediate‐dose (87/89, 97.8%) groups (p < 0.001). Rather than general KITmut, the specific KIT‐D816 independently led to a lower probability of achieving CR (HR = 3.29 [1.18–9.24], p = 0.023), worse EFS (HR = 3.53 [1.82–6.84], p < 0.001), and OS (HR = 5.45 [1.77–16.84], p = 0.003) in the standard‐dose group, but not in the intermediate‐dose group. CD19(+) represented the only independent factor predicting lower CIR both in the standard‐dose group (HR = 0.32 [0.10–1.00], p = 0.050) and in the intermediate‐dose group (HR = 0.11 [0.03–0.40], p = 0.001). When combined, KIT(+) plus CD19(−) conferred the most increased relapse risk (3‐year CIR 60%; SE 0.12). Specific KIT‐D816, instead of general KITmut, may be incorporated in prognostication model for t(8;21) AML. Combination of CD19 with KIT provides a more definite risk stratification profile for t(8;21) AML.
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Affiliation(s)
- Biao Wang
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
| | - Bin Yang
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
| | - Yun Ling
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
| | - Jihong Zhang
- Blood Research Laboratory, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoying Hua
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
| | - Weiying Gu
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
| | - Feng Yan
- Department of Hematology, Changzhou First People's Hospital, Changzhou, China
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19
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Jahn N, Terzer T, Sträng E, Dolnik A, Cocciardi S, Panina E, Corbacioglu A, Herzig J, Weber D, Schrade A, Götze K, Schröder T, Lübbert M, Wellnitz D, Koller E, Schlenk RF, Gaidzik VI, Paschka P, Rücker FG, Heuser M, Thol F, Ganser A, Benner A, Döhner H, Bullinger L, Döhner K. Genomic heterogeneity in core-binding factor acute myeloid leukemia and its clinical implication. Blood Adv 2020; 4:6342-6352. [PMID: 33351131 PMCID: PMC7757000 DOI: 10.1182/bloodadvances.2020002673] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 11/16/2020] [Indexed: 12/19/2022] Open
Abstract
Core-binding factor (CBF) acute myeloid leukemia (AML) encompasses AML with inv(16)(p13.1q22) and AML with t(8;21)(q22;q22.1). Despite sharing a common pathogenic mechanism involving rearrangements of the CBF transcriptional complex, there is growing evidence for considerable genotypic heterogeneity. We comprehensively characterized the mutational landscape of 350 adult CBF-AML [inv(16): n = 160, t(8;21): n = 190] performing targeted sequencing of 230 myeloid cancer-associated genes. Apart from common mutations in signaling genes, mainly NRAS, KIT, and FLT3, both CBF-AML entities demonstrated a remarkably diverse pattern with respect to the underlying cooperating molecular events, in particular in genes encoding for epigenetic modifiers and the cohesin complex. In addition, recurrent mutations in novel collaborating candidate genes such as SRCAP (5% overall) and DNM2 (6% of t(8;21) AML) were identified. Moreover, aberrations altering transcription and differentiation occurred at earlier leukemic stages and preceded mutations impairing proliferation. Lasso-penalized models revealed an inferior prognosis for t(8;21) AML, trisomy 8, as well as FLT3 and KIT exon 17 mutations, whereas NRAS and WT1 mutations conferred superior prognosis. Interestingly, clonal heterogeneity was associated with a favorable prognosis. When entering mutations by functional groups in the model, mutations in genes of the methylation group (ie, DNMT3A, TET2) had a strong negative prognostic impact.
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Affiliation(s)
- Nikolaus Jahn
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Tobias Terzer
- Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - Eric Sträng
- Department of Hematology, Oncology, Tumor Immunology, Charité University Medicine, Berlin, Germany
| | - Anna Dolnik
- Department of Hematology, Oncology, Tumor Immunology, Charité University Medicine, Berlin, Germany
| | - Sibylle Cocciardi
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Ekaterina Panina
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Andrea Corbacioglu
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Julia Herzig
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Anika Schrade
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Katharina Götze
- Department of Internal Medicine III, University Hospital Klinikum Rechts der Isar, Munich, Germany
| | - Thomas Schröder
- Department of Hematology, Oncology, and Clinical Immunology, University of Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Michael Lübbert
- Department of Internal Medicine I, Faculty of Medicine, University Hospital of Freiburg, Freiburg, Germany
| | - Dominique Wellnitz
- Department of Internal Medicine II, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Elisabeth Koller
- Department of Internal Medicine III, Hanuschkrankenhaus Wien, Wien, Austria
| | - Richard F Schlenk
- National Center of Tumor Diseases-Trial Center, German Cancer Research Center, Heidelberg, Germany
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany; and
| | - Verena I Gaidzik
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Peter Paschka
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Frank G Rücker
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center Heidelberg, Heidelberg, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Lars Bullinger
- Department of Hematology, Oncology, Tumor Immunology, Charité University Medicine, Berlin, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
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20
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Zhao X, Liu HQ, Wang LN, Yang L, Liu XL. Current and emerging molecular and epigenetic disease entities in acute myeloid leukemia and a critical assessment of their therapeutic modalities. Semin Cancer Biol 2020; 83:121-135. [PMID: 33242577 DOI: 10.1016/j.semcancer.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
Acute myeloid leukemia (AML) is the most frequently diagnosed acute leukemia, and its incidence increases with age. Although the etiology of AML remains unknown, exposure to genotoxic agents or some prior hematologic disorders could lead to the development of this condition. The pathogenesis of AML involves the development of malignant transformation of hematopoietic stem cells that undergo successive genomic alterations, ultimately giving rise to a full-blown disease. From the disease biology perspective, AML is considered to be extremely complex with significant genetic, epigenetic, and phenotypic variations. Molecular and cytogenetic alterations in AML include mutations in those subsets of genes that are involved in normal cell proliferation, maturation and survival, thus posing significant challenge to targeting these pathways without attendant toxicity. In addition, multiple malignant cells co-exist in the majority of AML patients. Individual subclones are characterized by unique genetic and epigenetic abnormalities, which contribute to the differences in their response to treatment. As a result, despite a dramatic progress in our understanding of the pathobiology of AML, not much has changed in therapeutic approaches to treat AML in the past four decades. Dose and regimen modifications with improved supportive care have contributed to improved outcomes by reducing toxicity-related side effects. Several drug candidates are currently being developed, including targeted small-molecule inhibitors, cytotoxic chemotherapies, monoclonal antibodies and epigenetic drugs. This review summarizes the current state of affairs in the pathobiological and therapeutic aspects of AML.
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Affiliation(s)
- Xin Zhao
- Department of Paediatrics, The First Hospital of Jilin University, Changchun, China
| | - Huan-Qiu Liu
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, China
| | - Li-Na Wang
- Department of Paediatrics, The First Hospital of Jilin University, Changchun, China
| | - Le Yang
- Department of Endocrinology, The People's Hospital of Jilin Province, Changchun, China.
| | - Xiao-Liang Liu
- Department of Hematology, The First Hospital of Jilin University, Changchun, China.
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21
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Hou HA, Tien HF. Genomic landscape in acute myeloid leukemia and its implications in risk classification and targeted therapies. J Biomed Sci 2020; 27:81. [PMID: 32690020 PMCID: PMC7372828 DOI: 10.1186/s12929-020-00674-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy in terms of clinical features, underlying pathogenesis and treatment outcomes. Recent advances in genomic techniques have unraveled the molecular complexity of AML leukemogenesis, which in turn have led to refinement of risk stratification and personalized therapeutic strategies for patients with AML. Incorporation of prognostic and druggable genetic biomarkers into clinical practice to guide patient-specific treatment is going to be the mainstay in AML therapeutics. Since 2017 there has been an explosion of novel treatment options to tailor personalized therapy for AML patients. In the past 3 years, the U.S. Food and Drug Administration approved a total of eight drugs for the treatment of AML; most specifically target certain gene mutations, biological pathways, or surface antigen. These novel agents are especially beneficial for older patients or those with comorbidities, in whom the treatment choice is limited and the clinical outcome is very poor. How to balance efficacy and toxicity to further improve patient outcome is clinically relevant. In this review article, we give an overview of the most relevant genetic markers in AML with special focus on the therapeutic implications of these aberrations.
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Affiliation(s)
- Hsin-An Hou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hwei-Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan.
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22
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Kirtonia A, Pandya G, Sethi G, Pandey AK, Das BC, Garg M. A comprehensive review of genetic alterations and molecular targeted therapies for the implementation of personalized medicine in acute myeloid leukemia. J Mol Med (Berl) 2020; 98:1069-1091. [PMID: 32620999 DOI: 10.1007/s00109-020-01944-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/18/2020] [Accepted: 06/22/2020] [Indexed: 12/17/2022]
Abstract
Acute myeloid leukemia (AML) is an extremely heterogeneous disease defined by the clonal growth of myeloblasts/promyelocytes not only in the bone marrow but also in peripheral blood and/or tissues. Gene mutations and chromosomal abnormalities are usually associated with aberrant proliferation and/or block in the normal differentiation of hematopoietic cells. So far, the combination of cytogenetic profiling and molecular and gene mutation analyses remains an essential tool for the classification, diagnosis, prognosis, and treatment for AML. This review gives an overview on how the development of novel innovative technologies has allowed us not only to detect the genetic alterations as early as possible but also to understand the molecular pathogenesis of AML to develop novel targeted therapies. We also discuss the remarkable advances made during the last decade to understand the AML genome both at primary and relapse diseases and how genetic alterations might influence the distinct biological groups as well as the clonal evolution of disease during the diagnosis and relapse. Also, the review focuses on how the persistence of epigenetic gene mutations during morphological remission is associated with relapse. It is suggested that along with the prognostic and therapeutic mutations, the novel molecular targeted therapies either approved by FDA or those under clinical trials including CART-cell therapy would be of immense importance in the effective management of AML.
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Affiliation(s)
- Anuradha Kirtonia
- Amity Institute of Molecular Medicine and Stem Cell Research (AIMMSCR), Amity University, Noida, Uttar Pradesh, 201313, India
| | - Gouri Pandya
- Amity Institute of Molecular Medicine and Stem Cell Research (AIMMSCR), Amity University, Noida, Uttar Pradesh, 201313, India
| | - Gautam Sethi
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Amit Kumar Pandey
- Amity Institute of Biotechnology (AIB), Amity University, Gurgaon, Haryana, 122413, India
| | - Bhudev C Das
- Amity Institute of Molecular Medicine and Stem Cell Research (AIMMSCR), Amity University, Noida, Uttar Pradesh, 201313, India
| | - Manoj Garg
- Amity Institute of Molecular Medicine and Stem Cell Research (AIMMSCR), Amity University, Noida, Uttar Pradesh, 201313, India.
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23
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RAF Kinase Inhibitor Protein in Myeloid Leukemogenesis. Int J Mol Sci 2019; 20:ijms20225756. [PMID: 31744053 PMCID: PMC6888401 DOI: 10.3390/ijms20225756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023] Open
Abstract
RAF kinase inhibitor protein (RKIP) is an essential regulator of intracellular signaling. A somatic loss of RKIP expression is a frequent event in solid human cancers, and a role of RKIP as metastasis-suppressor is widely accepted nowadays. Recently, RKIP loss has been described in acute myeloid leukemia (AML) and a series of other myeloid neoplasias (MNs). Functional in vitro and in vivo experiments revealed that RKIP is an essential player within the development of these liquid tumors; however, the respective role of RKIP seems to be complex and multi-faceted. In this review, we will summarize the current knowledge about RKIP in myeloid leukemogenesis. We will initially describe its involvement in physiologic hematopoiesis, and will then proceed to discuss its role in the development of AML and other MNs. Finally, we will discuss potential therapeutic implications arising thereof.
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24
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Chung W, Kelly AD, Kropf P, Fung H, Jelinek J, Su XY, Roboz GJ, Kantarjian HM, Azab M, Issa JPJ. Genomic and epigenomic predictors of response to guadecitabine in relapsed/refractory acute myelogenous leukemia. Clin Epigenetics 2019; 11:106. [PMID: 31331399 PMCID: PMC6647096 DOI: 10.1186/s13148-019-0704-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023] Open
Abstract
Background Guadecitabine is a novel DNA methyltransferase (DNMT) inhibitor with improved pharmacokinetics and clinical activity in a subset of patients with relapsed/refractory acute myeloid leukemia (r/r AML), but identification of this subset remains difficult. Methods To search for biomarkers of response, we measured genome-wide DNA methylation, mutations of 54 genes, and expression of a panel of 7 genes in pre-treatment samples from 128 patients treated at therapeutic doses in a phase I/II study. Results Response rate to guadecitabine was 17% (2 complete remission (CR), 3 CR with incomplete blood count recovery (CRi), or CR with incomplete platelets recovery (CRp)) in the phase I component and 23% (14 CR, 9 CRi/CRp) in phase II. There were no strong mutation or methylation predictors of response. Gene expression clustering defined a subset of patients (~ 20%) that had (i) high DNMT3B and low CDKN2B, CTCF, and CDA expression; (ii) enrichment for KRAS/NRAS mutations; (iii) frequent CpG island hypermethylation; (iv) low long interspersed nuclear element 1 (LINE-1) hypomethylation after treatment; and (v) resistance to guadecitabine in both phase I (response rate 0% vs. 33%, p = 0.07) and phase II components of the study (response rate 5% vs. 30%, p = 0.02). Multivariate analysis identified peripheral blood (PB) blasts and hemoglobin as predictors of response and cytogenetics, gene expression, RAS mutations, and hemoglobin as predictors of survival. Conclusions A subset of patients (~ 20%) with r/r AML is unlikely to benefit from guadecitabine as a single agent. In the remaining 80%, guadecitabine is a viable option with a median survival of 8 months and a 2-year survival rate of 21%. Trial registration NCT01261312. Electronic supplementary material The online version of this article (10.1186/s13148-019-0704-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Woonbok Chung
- Fels Institute for Cancer Research and Molecular Biology, Temple University School of Medicine, Philadelphia, PA, USA. .,Present address: Coriell Institute for Medical Research, 403 Haddon Ave, Camden, NJ, 08103, USA.
| | - Andrew D Kelly
- Fels Institute for Cancer Research and Molecular Biology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Patricia Kropf
- Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
| | - Henry Fung
- Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
| | - Jaroslav Jelinek
- Fels Institute for Cancer Research and Molecular Biology, Temple University School of Medicine, Philadelphia, PA, USA.,Present address: Coriell Institute for Medical Research, 403 Haddon Ave, Camden, NJ, 08103, USA
| | | | - Gail J Roboz
- Weill Cornell Medicine, Division of Hematology and Oncology, The New York Presbyterian Hospital, New York, NY, USA
| | | | | | - Jean-Pierre J Issa
- Fels Institute for Cancer Research and Molecular Biology, Temple University School of Medicine, Philadelphia, PA, USA.,Present address: Coriell Institute for Medical Research, 403 Haddon Ave, Camden, NJ, 08103, USA
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25
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Evolution of a chemosensitive core-binding factor AML into an aggressive leukemia with eosinophilic differentiation. Blood Adv 2019; 2:1517-1521. [PMID: 29950292 DOI: 10.1182/bloodadvances.2018016675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/19/2018] [Indexed: 11/20/2022] Open
Abstract
Key Points
Core-binding factor AML can evolve from good-risk disease into aggressive disease through the gain of additional genomic aberrations. In this unique case, an AML patient died of hypereosinophilic syndrome with solid organ infiltration of differentiated eosinophils.
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26
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Ye F, Chai W, Xie M, Yang M, Yu Y, Cao L, Yang L. HMGB1 regulates erastin-induced ferroptosis via RAS-JNK/p38 signaling in HL-60/NRAS Q61L cells. Am J Cancer Res 2019; 9:730-739. [PMID: 31105999 PMCID: PMC6511643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 06/09/2023] Open
Abstract
Ferroptosis is emerging as a new form of regulated cell death driven by oxidative injury promoting lipid peroxidation in an iron-dependent manner. High mobility group box 1 (HMGB1) plays an important role in leukemia pathogenesis and chemotherapy resistance. The mechanisms of ferroptosis in tumor pathogenesis and treatment have been a recent research focus but the role of HMGB1 in regulating ferroptosis especially in leukemia still remains largely unknown. Here, we shown that HMGB1 is a critical regulator of eratin-induced ferroptosis in HL-60 cell line expressing NRASQ61L (HL-60/NRASQ61L). Erastin enhanced ROS levels, thereby promoting cytosolic translocation of HMGB1 and enhancing cell death. Knockdown of HMGB1 decreased erastin-induced ROS generation and cell death in an iron-mediated lysosomal pathway in HL-60/NRASQ61L cells. Knockdown of HMGB1 or rat sarcoma (RAS), or pharmacological inhibition of JNK and p38 decreased TfR1 levels in HL-60/NRASQ61L cells. Importantly, these data were further supported by our in vivo experiment, in which xenografts formed by HMGB1 knockdown HL-60/NRASQ61L cells had lower PTGS2 and TfR1 expression than that in control mice. Taken together, these results suggest that HMGB1 is a novel regulator of ferroptosis via the RAS-JNK/p38 pathway and a potential drug target for therapeutic interventions in leukemia.
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Affiliation(s)
- Fanghua Ye
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
| | - Wenwen Chai
- Department of Nuclear Medicine, Hunan Cancer HospitalChangsha 410008, Hunan, People’s Republic of China
| | - Min Xie
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
| | - Minghua Yang
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
| | - Yan Yu
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
| | - Lizhi Cao
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
| | - Liangchun Yang
- Department of Pediatrics, Xiangya Hospital, Central South UniversityChangsha 410008, Hunan, People’s Republic of China
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27
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Liu K, Guo J, Liu K, Fan P, Zeng Y, Xu C, Zhong J, Li Q, Zhou Y. Integrative analysis reveals distinct subtypes with therapeutic implications in KRAS-mutant lung adenocarcinoma. EBioMedicine 2018; 36:196-208. [PMID: 30268834 PMCID: PMC6197714 DOI: 10.1016/j.ebiom.2018.09.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/11/2018] [Accepted: 09/19/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND KRAS-mutant lung adenocarcinomas (LUADs) are heterogeneous and frequently occur in smokers. The heterogeneity of KRAS-mutant LUAD has been an obstacle for the drug discovery. METHODS We integrated multiplatform datatypes and identified two corresponding subtypes in the patients and cell lines. We further characterized the features of these two subtypes and performed drug screening to identify subtype-specific drugs. Finally, we used the defining features of the KRAS subtypes for drug sensitivity prediction. FINDINGS Patient-Subtype 1 (PS1) was characterized by increased smoking-related mutational signature activity, a low tumor-infiltrating lymphocyte (TIL)-associating score and STK11/KEAP1 co-mutations. Patient-Subtype 2 (PS2) was characterized by an increased smoking-related methylation signature activity, a high TIL-associating score and increased KRAS dependency. The cell line subtypes faithfully recapitulated all the patients' features. Drug screening of the two cell line subtypes yielded several potential candidates, such as cytarabine and enzastaurin for Cell-line-Subtype 1 (CS1) and a BTK inhibitor QL-XII-61 for Cell-line-Subtype 2 (CS2). The defining features, such as smoking-related methylation signature, were significantly associated with the sensitivity to several drugs. INTERPRETATION The heterogeneity of KRAS-mutant LUAD is associated with smoking-related genomic and epigenomic aberration along with other features such as immunogenicity, KRAS dependency and STK11/KEAP1 co-mutations. These features might be used as biomarkers for drug sensitivity prediction. FUND: This research was funded by the Young Scientists Fund of the National Natural Science Foundation of China, the Natural Science Foundation of Fujian Province, China and the Education and Research Foundation for Young Scholars of Education Department of Fujian Province, China.
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Affiliation(s)
- Ke Liu
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Jintao Guo
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Kuai Liu
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Peiyang Fan
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Yuanyuan Zeng
- BGI-Shenzhen, Bei Shan Industrial Zone, Yantian District, Shenzhen, Guangdong Province 518083, China
| | - Chaoqun Xu
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Jiaxin Zhong
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China
| | - Qiyuan Li
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China.
| | - Ying Zhou
- Department of Translational Medicine, Medical College of Xiamen University, Xiamen 361102, China; Center for Biomedical Big Data Research, Medical College of Xiamen University, Xiamen 361102, China.
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28
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Saikia M, Retnakumari AP, Anwar S, Anto NP, Mittal R, Shah S, Pillai KS, Balachandran VS, Peter V, Thomas R, Anto RJ. Heteronemin, a marine natural product, sensitizes acute myeloid leukemia cells towards cytarabine chemotherapy by regulating farnesylation of Ras. Oncotarget 2018; 9:18115-18127. [PMID: 29719594 PMCID: PMC5915061 DOI: 10.18632/oncotarget.24771] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/23/2018] [Indexed: 12/25/2022] Open
Abstract
Cytarabine is a conventionally used chemotherapeutic agent for treating acute myeloid leukemia (AML). However, chemoresistance, toxic side-effects and poor patient survival rates retard the efficacy of its performance. The current study deals with the chemosensitization of AML cells using heteronemin, a marine natural product towards cytarabine chemotherapy. Heteronemin could effectively sensitize HL-60 cells towards sub-toxic concentration of cytarabine resulting in synergistic toxicity as demonstrated by MTT assay and [3H] thymidine incorporation studies, while being safe towards healthy blood cells. Flow cytometry for Annexin-V/PI and immunoblotting for caspase cleavage proved that the combination induces enhancement in apoptosis. Heteronemin being a farnesyl transferase inhibitor (FTI) suppressed cytarabine-induced, farnesyl transferase-mediated activation of Ras, as assessed by Ras pull-down assay. Upon pre-treating cells with a commercial FTI, L-744,832, the synergism was completely lost in the combination, confirming the farnesyl transferase inhibitory activity of heteronemin as assessed by thymidine incorporation assay. Heteronemin effectively down-regulated cytarabine-induced activation of MAPK, AP-1, NF-κB and c-myc, the down-stream targets of Ras signaling, which again validated the role of Ras in regulating the synergism. Hence we believe that the efficacy of cytarabine chemotherapy can be improved to a significant extent by combining sub-toxic concentrations of cytarabine and heteronemin.
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Affiliation(s)
- Minakshi Saikia
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
- Research Scholar, University of Kerala, India
| | - Archana P Retnakumari
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Shabna Anwar
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
- Research Scholar, University of Kerala, India
| | - Nikhil P Anto
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Rashmi Mittal
- Department of Biotechnology, Maharishi Markandeshwar University, Haryana, India
| | - Shabna Shah
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
- Research Scholar, University of Kerala, India
| | - Kavya S Pillai
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
- Research Scholar, University of Kerala, India
| | - Vinod S Balachandran
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Vidya Peter
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Reeba Thomas
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Ruby John Anto
- Division of Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
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29
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Ohanian M, Tari Ashizawa A, Garcia-Manero G, Pemmaraju N, Kadia T, Jabbour E, Ravandi F, Borthakur G, Andreeff M, Konopleva M, Lim M, Pierce S, O'Brien S, Alvarado Y, Verstovsek S, Wierda W, Kantarjian H, Cortes J. Liposomal Grb2 antisense oligodeoxynucleotide (BP1001) in patients with refractory or relapsed haematological malignancies: a single-centre, open-label, dose-escalation, phase 1/1b trial. Lancet Haematol 2018; 5:e136-e146. [PMID: 29550383 DOI: 10.1016/s2352-3026(18)30021-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Activating mutations of tyrosine kinases are common in leukaemias. Oncogenic tyrosine kinases use the growth factor receptor-bound protein 2 (Grb2) for signal transduction, leading to activation of mitogen-activated protein kinase (MAPK) 1 and MAPK3 (ERK2 and ERK1). We hypothesised that inhibition of Grb2 would suppress ERK1 and ERK2 activation and inhibit leukaemia progression. To inhibit Grb2, a liposome-incorporated antisense oligodeoxynucleotide that blocks Grb2 protein expression, BP1001, was developed. We report the first phase 1 findings of BP1001. METHODS In this single-centre, open-label, dose-escalation phase 1/1b trial, we enrolled participants (aged ≥18 years) with refractory or relapsed acute myeloid leukaemia, Philadelphia-chromosome-positive chronic myeloid leukaemia (in chronic, accelerated, or blast phase), acute lymphoblastic leukaemia, or myelodysplastic syndrome, at MD Anderson Cancer Center (Houston, TX, USA). We used a 3 + 3 dose escalation strategy, with at least three patients enrolled at each dose level. We administered BP1001 intravenously, twice weekly, for 28 days, with a starting dose of 5 mg/m2. If two or more patients developed toxic effects of grade 3 or higher, that dose level was deemed toxic. The dose was escalated if it did not produce dose-limiting toxic effects, and patients would be sequentially enrolled into cohort 2 (10 mg/m2), cohort 3 (20 mg/m2), cohort 4 (40 mg/m2), cohort 5 (60 mg/m2), or cohort 6 (90 mg/m2). After completion of monotherapy, we assessed the safety and toxicity of BP1001 (60 or 90 mg/m2) in combination with 20 mg low-dose cytarabine (twice-daily subcutaneous injections) in a phase 1b study in patients with refractory or relapsed acute myeloid leukaemia (ie, those who were refractory to at least one previous therapy regimen and no more than one previous salvage regimen). The objectives of this study were to establish the toxicity and tolerance of escalating doses of BP1001 monotherapy in patients with refractory or relapsed leukaemia, to assess the maximum tolerated dose of BP1001, and to determine the optimal biologically active dose of BP1001, defined as a 50% reduction in Grb2 expression in circulating leukaemia cells. We also aimed to assess the in-vivo pharmacokinetics of BP1001 and tumour response. The study is completed and is registered with ClinicalTrials.gov, number NCT01159028. FINDINGS Between July 23, 2010, and Feb 23, 2016, we enrolled and treated 39 patients, of whom 27 were assessable for dose-limiting toxicity. The first patient treated had mucositis and hand-foot syndrome, which were assessed as possibly related to BP1001 and counted as a dose-limiting toxicity. We noted no other dose-limiting toxicities, and a maximum tolerated dose was not identified. The highest tested dose of BP1001 was 90 mg/m2. The most common grade 3-4 adverse events were cardiopulmonary disorders (25 [64%] of 39 patients), and fever (including neutropenic fever) and infections (17 [44%] patients). Grade 5 adverse events were cardiopulmonary disorders (two [5%] of 39 patients), fever (including neutropenic fever) and infections (two [5%] of 39 patients), and multi-organ failure (one [3%] of 39 patients). Nine (33%) of 27 patients who had peripheral blood blasts at the start of therapy had a reduction of 50% or more in peripheral blood blasts while receiving BP1001 montherapy. Three (10%) of 29 patients who had bone marrow blasts at the start of therapy had a reduction in bone marrow blasts of 50% or more while receiving BP1001 monotherapy. Per investigator's assessment, seven (22%) of 32 patients benefited from BP1001 monotherapy and had extended cycles of treatment. Of seven patients receiving BP1001 plus low-dose cytarabine combination therapy, two had complete remission, one had complete remission with incomplete haematological recovery, and two had stable disease with no dose-limiting toxicity; one patient died and one withdrew, both because of disease progression. There were eight deaths; none were treatment related. INTERPRETATION BP1001 is well tolerated, with early evidence of anti-leukaemic activity in combination with low-dose cytarabine. To further explore this anti-leukaemic activity, the efficacy of BP1001 plus low-dose cytarabine combination is being investigated in an ongoing phase 2 study in patients with previously untreated acute myeloid leukaemia who are ineligible for intensive induction therapy. FUNDING Bio-Path Holdings Inc.
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Affiliation(s)
- Maro Ohanian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Naveen Pemmaraju
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Andreeff
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miranda Lim
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Yesid Alvarado
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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30
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McCurdy SR, Levis MJ. Emerging molecular predictive and prognostic factors in acute myeloid leukemia. Leuk Lymphoma 2017; 59:2021-2039. [DOI: 10.1080/10428194.2017.1393669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Shannon R. McCurdy
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark J. Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Abstract
Myeloid malignancies exist on a spectrum from asymptomatic clonal hematopoiesis to overt leukemia and exhibit substantial clonal heterogeneity. Both aspects are challenging to capture in experimental models. In two landmark studies in this issue of Cell Stem Cell, Kotini et al. (2017) and Chao et al. (2017) establish iPSC-based experimental platforms that recapitulate disease stages and clonal architecture.
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Affiliation(s)
- Kathrin M Bernt
- The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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32
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Pomeroy EJ, Eckfeldt CE. Targeting Ras signaling in AML: RALB is a small GTPase with big potential. Small GTPases 2017; 11:39-44. [PMID: 28682649 DOI: 10.1080/21541248.2017.1339765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Acute myeloid leukemia (AML) is a devastating malignancy for which novel treatment approaches are desperately needed. Ras signaling is an attractive therapeutic target for AML because a large proportion of AMLs have mutations in NRAS, KRAS, or genes that activate Ras signaling, and key Ras effectors are activated in virtually all AML patient samples. This has inspired efforts to develop Ras-targeted treatment strategies for AML. Due to the inherent difficulty and disappointing efficacy of targeting Ras proteins directly, many have focused on inhibiting Ras effector pathways. Inhibiting the major oncogenic Ras effectors, the mitogen-activated protein kinase (MAPK) and/or phosphatidylinositiol-3-kinase (PI3K) pathways, has generally demonstrated modest efficacy for AML. While this may be in part related to functional redundancy between these pathways, it is now clear that other Ras effectors have key oncogenic roles. Specifically, the Ras-like (Ral) GTPases have emerged as critical mediators of Ras-driven transformation and AML cell survival. Our group recently uncovered a critical role for RALB signaling in leukemic cell survival and a potential mediator of relapse following Ras-targeted therapy in AML. Furthermore, we found that RALB signaling is hyperactivated in AML patient samples, and inhibiting RALB has potent anti-leukemic activity in preclinical AML models. While key questions remain regarding the importance of RALB signaling across the genetically diverse spectrum of AML, the specific mechanism(s) that promotes leukemic cell survival downstream of RALB, and how to pharmacologically target RALB signaling effectively - RALB has emerged as a critical Ras effector and potential therapeutic target for AML.
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Affiliation(s)
- Emily J Pomeroy
- Department of Medicine, Division of Hematology, Oncology, & Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Craig E Eckfeldt
- Department of Medicine, Division of Hematology, Oncology, & Transplantation, University of Minnesota, Minneapolis, MN, USA.,Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
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33
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Genetic deletion or small-molecule inhibition of the arginine methyltransferase PRMT5 exhibit anti-tumoral activity in mouse models of MLL-rearranged AML. Leukemia 2017; 32:499-509. [PMID: 28663579 DOI: 10.1038/leu.2017.206] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/31/2017] [Accepted: 06/21/2017] [Indexed: 12/13/2022]
Abstract
The hematological malignancies classified as mixed lineage leukemias (MLL) harbor fusions of the MLL1 gene to partners that are members of transcriptional elongation complexes. MLL-rearranged leukemias are associated with extremely poor prognosis, and response to conventional therapies and efforts to identify molecular targets are urgently needed. Using mouse models of MLL-rearranged acute myeloid leukemia, here we show that genetic inactivation or small-molecule inhibition of the protein arginine methyltransferase PRMT5 exhibit anti-tumoral activity in MLL-fusion protein-driven transformation. Genome-wide transcriptional analysis revealed that inhibition of PRMT5 methyltransferase activity overrides the differentiation block in leukemia cells without affecting the expression of MLL-fusion direct oncogenic targets. Furthermore, we find that this differentiation block is mediated by transcriptional silencing of the cyclin-dependent kinase inhibitor p21 (CDKN1a) gene in leukemia cells. Our study provides pre-clinical rationale for targeting PRMT5 using small-molecule inhibitors in the treatment of leukemias harboring MLL rearrangements.
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34
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Neubauer A. [Immunotherapy of cancer with checkpoint inhibitors : Not only in malignant melanoma]. Internist (Berl) 2017; 58:409-423. [PMID: 28303311 DOI: 10.1007/s00108-017-0208-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The newest weapon in cancer therapy is checkpoint inhibition, which is the result of basic immunology research. The success of this therapy is based on the fact that upon light microscopy, many solid tumors harbor lymphocytic cells infiltrating the tumor (TILs), and in many solid tumors, the presence of these TILs are prognostic. Ipilimumab was the first monoclonal antibody developed against a target present on T cells after becoming activated, CTLA-4. In malignant melanoma, ipilimumab showed its beneficial effect as compared to a placebo peptide. However, the therapy with this antibody harbors significant toxicity. Meanwhile, other targets such as PD-1, also expressed on (late) activated T cells, were identified, and therapies with antibodies inhibiting PD-1/PD-L1 are less toxic. Although these antibodies show response only in a minority of patients, the benefit seems durable in some of these patients. In solid tumors such as melanoma or non-small cell lung cancer (NSCLC), treatment with PD-1 inhibitors has resulted in a significant prolongation of survival, even in first-line treatment. As these drugs have been approved in many indications, it is important to know the drugs and side effects. Resistance towards these drugs are caused by low expression of the natural ligand, PD-L1, in the tumor tissue, as well as acquired loss of signal transduction of interferon-related genes such as JAK1 or JAK2, respectively. Also new in cancer therapy are bispecific T cell engager monoclonal antibodies (BiTEs) such as blinatumomab, and autologous chimeric antigen receptor-modified T cells (CAR-Ts). The later have proven their efficacy mainly in hematological neoplasias such as precursor-B-ALL. The dramatic costs of all these new drugs will have an enormous impact on the health care systems in the near future.
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Affiliation(s)
- A Neubauer
- Zentrum Innere Medizin, Klinik für Hämatologie, Onkologie und Immunologie, Philipps-Universität Marburg, Universitätsklinikum Gießen und Marburg, Baldingerstr. 1, 35033, Marburg, Deutschland. .,Carreras Leukämie Centrum, Philipps-Universität Marburg, Universitätsklinikum Gießen und Marburg, Marburg, Deutschland.
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35
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Salem D, El-Aziz SA, El-Menshawy N, Abouzeid T, Ebrahim M. Prevalence and Prognostic Value of IDH1 R132 Mutation in Newly Diagnosed AML Egyptian Patients with Normal Karyotype. Indian J Hematol Blood Transfus 2017; 33:49-55. [PMID: 28194056 DOI: 10.1007/s12288-016-0649-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/15/2016] [Indexed: 10/22/2022] Open
Abstract
Mutation in IDH1 gene was suggested to be associated with bad prognosis in cytogenetically normal AML (CN-AML). However, there are conflicting data about its prognostic impact. Besides, its prevalence and prognostic significance in Egyptian patients still not fully stated. We aimed to assess the prevalence of IDH1R132 mutation in Egyptian CN-AML patients, its correlation with FAB subtypes, and clinical outcome of those patients. Sequencing of amplified IDH1 gene exon four from 50 patients was performed to detect codon R132 point mutation. High prevalence of IDH1 mutation was detected in our patients (9/50, 18 %). Mutated IDH1R132 was associated with older age and higher platelets count (p = 0.04 and 0.01 respectively). The most common FAB subtype associated with mutated IDH1R132 was AML-M2 followed by M4. In multivariate analysis, IDH1R132 mutation was found as independent prognostic variable. It was significantly associated with lower CR and shorter OS (p = 0.06 and 0.009 respectively).
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Affiliation(s)
- Dalia Salem
- Clinical Pathology Department, Oncology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Sherin Abd El-Aziz
- Clinical Pathology Department, Oncology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Nadia El-Menshawy
- Clinical Pathology Department, Oncology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Tarek Abouzeid
- Clinical Pathology Department, Oncology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Mohamed Ebrahim
- Medical Oncology Unit, Oncology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
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36
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Fu JF, Liang ST, Huang YJ, Liang KH, Yen TH, Liang DC, Shih LY. Cooperation of MLL/AF10(OM-LZ) with PTPN11 activating mutation induced monocytic leukemia with a shorter latency in a mouse bone marrow transplantation model. Int J Cancer 2016; 140:1159-1172. [PMID: 27859216 DOI: 10.1002/ijc.30515] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/04/2016] [Indexed: 01/05/2023]
Abstract
PTPN11 mutation, a RAS signaling pathway mutation, is associated with MLL translocations in acute leukemia. A girl with MLL/AF10 AML was found to carry PTPN11G503A . To study the impact of PTPN11G503A cooperating with MLL/AF10 on leukemogenesis, we established a retroviral transduction/transplantation mouse model. Compared to the MLL/AF10(OM-LZ) leukemia cells harboring PTPN11wt , the cells harboring PTPN11G503A were hypersensitive to GM-CSF and IL3, and more resistant to death upon treatment with daunorubicin but sensitive to cytarabine. The cells harboring PTPN11G503A autonomously differentiated into macrophages (1.8%) in the medium containing IL3. Further studies showed that the cells had an elevated (∼2.9-fold) Csf1 transcription level and secreted more (∼4.5-fold) M-CSF to the medium which can stimulate monocyte/macrophage differentiation of BM cells. Mice transplanted with the cells harboring PTPN11G503A had a higher concentration of M-CSF in plasma. When mixed with the MLL/AF10(OM-LZ) leukemia cells harboring PTPN11wt , the cells harboring PTPN11G503A had an increased competitive engraftment and clonal expansion in the BM and spleen of recipient mice, although no competitive growth advantage was observed in the in vitro co-culturing assays. The mice transplanted with the MLL/AF10(OM-LZ) cells harboring PTPN11wt developed myelomonocytic leukemia, while those transplanted with the cells harboring PTPN11G503A -induced monocytic leukemia in a shorter latency. Our results demonstrated that addition of PTPN11G503A to MLL/AF10 affected cell proliferation, chemo-resistance, differentiation, in vivo BM recruitment/clonal expansion and accelerated disease progression.
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Affiliation(s)
- Jen-Fen Fu
- Department of Medical Research, Chang Gung Memorial Hospital, and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Sung-Tzu Liang
- Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ying-Jung Huang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kung-Hao Liang
- Liver Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Der-Cherng Liang
- Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Internal Medicine, Chang Gung University, Taoyuan, Taiwan
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37
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Taccioli C, Sorrentino G, Zannini A, Caroli J, Beneventano D, Anderlucci L, Lolli M, Bicciato S, Del Sal G. MDP, a database linking drug response data to genomic information, identifies dasatinib and statins as a combinatorial strategy to inhibit YAP/TAZ in cancer cells. Oncotarget 2016; 6:38854-65. [PMID: 26513174 PMCID: PMC4770742 DOI: 10.18632/oncotarget.5749] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/05/2015] [Indexed: 02/07/2023] Open
Abstract
Targeted anticancer therapies represent the most effective pharmacological strategies in terms of clinical responses. In this context, genetic alteration of several oncogenes represents an optimal predictor of response to targeted therapy. Integration of large-scale molecular and pharmacological data from cancer cell lines promises to be effective in the discovery of new genetic markers of drug sensitivity and of clinically relevant anticancer compounds. To define novel pharmacogenomic dependencies in cancer, we created the Mutations and Drugs Portal (MDP, http://mdp.unimore.it), a web accessible database that combines the cell-based NCI60 screening of more than 50,000 compounds with genomic data extracted from the Cancer Cell Line Encyclopedia and the NCI60 DTP projects. MDP can be queried for drugs active in cancer cell lines carrying mutations in specific cancer genes or for genetic markers associated to sensitivity or resistance to a given compound. As proof of performance, we interrogated MDP to identify both known and novel pharmacogenomics associations and unveiled an unpredicted combination of two FDA-approved compounds, namely statins and Dasatinib, as an effective strategy to potently inhibit YAP/TAZ in cancer cells.
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Affiliation(s)
- Cristian Taccioli
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy
| | - Giovanni Sorrentino
- Laboratorio Nazionale CIB (LNCIB), Area Science Park, Trieste 34149, Italy.,Dipartimento di Scienze della Vita, Università degli Studi di Trieste, Trieste 34149, Italy
| | - Alessandro Zannini
- Laboratorio Nazionale CIB (LNCIB), Area Science Park, Trieste 34149, Italy.,Dipartimento di Scienze della Vita, Università degli Studi di Trieste, Trieste 34149, Italy
| | - Jimmy Caroli
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy
| | | | | | - Marco Lolli
- Department of Science and Drug Technology, University of Torino, Torino 10125, Italy
| | - Silvio Bicciato
- Department of Life Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy
| | - Giannino Del Sal
- Laboratorio Nazionale CIB (LNCIB), Area Science Park, Trieste 34149, Italy.,Dipartimento di Scienze della Vita, Università degli Studi di Trieste, Trieste 34149, Italy
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38
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Prada-Arismendy J, Arroyave JC, Röthlisberger S. Molecular biomarkers in acute myeloid leukemia. Blood Rev 2016; 31:63-76. [PMID: 27639498 DOI: 10.1016/j.blre.2016.08.005] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 08/24/2016] [Accepted: 08/26/2016] [Indexed: 12/11/2022]
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults. The pathophysiology of this disease is just beginning to be understood at the cellular and molecular level, and currently cytogenetic markers are the most important for risk stratification and treatment of AML patients. However, with the advent of new technologies, the detection of other molecular markers such as point mutations and characterization of epigenetic and proteomic profiles, have begun to play an important role in how the disease is approached. Recent evidence shows that the identification of new AML biomarkers contributes to a better understanding of the molecular basis of the disease, is significantly useful in screening, diagnosis, prognosis and monitoring of AML, as well as the possibility of predicting each individual's response to treatment. This review summarizes the most relevant molecular (genetic, epigenetic, and protein) biomarkers associated with acute myeloid leukemia and discusses their clinical importance in terms of risk prediction, diagnosis and prognosis.
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MESH Headings
- Biomarkers, Tumor
- DNA Methylation
- Disease Susceptibility
- Epigenesis, Genetic
- Genetic Variation
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/mortality
- Mutation
- Prognosis
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Affiliation(s)
- Jeanette Prada-Arismendy
- Grupo de Investigación e Innovación Biomédica, Instituto Tecnológico Metropolitano, Medellín, Colombia.
| | - Johanna C Arroyave
- Grupo de Investigación e Innovación Biomédica, Instituto Tecnológico Metropolitano, Medellín, Colombia
| | - Sarah Röthlisberger
- Grupo de Investigación e Innovación Biomédica, Instituto Tecnológico Metropolitano, Medellín, Colombia
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39
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Zhang DY, Yuan XQ, Yan H, Cao S, Zhang W, Li XL, Zeng H, Chen XP. Association between DCK 35708 T>C variation and clinical outcomes of acute myeloid leukemia in South Chinese patients. Pharmacogenomics 2016; 17:1519-31. [PMID: 27548009 DOI: 10.2217/pgs-2016-0084] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIM DCK is a rate-limiting enzyme in cytarabine activation. rs4643786 and rs67437265 (P122S) variants are reported to affect DCK activity. PATIENTS & METHODS A total of 282 newly diagnosed acute myeloid leukemia (AML) patients were treated with cytarabine combined chemotherapy and genotyped for rs4643786 and rs67437265. Prognosis data were obtained through regular follow-up. DCK mRNA expression was detected in pretreatment blood or bone marrow mononuclear cells. RESULTS rs4643786 showed strong linkage disequilibrium with rs67437265. rs4643786 CT heterozygotes showed significantly higher complete remission rate (p = 0.028), superior overall survival (p = 0.006) and relapse-free survival (p = 0.020) than wild-type TT homozygotes. rs4643786 polymorphism was an independent predictor for AML prognosis. CONCLUSION DCK rs4643786 may serve as an independent predictor of drug response and AML outcome.
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Affiliation(s)
- Dao-Yu Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China
| | - Xiao-Qing Yuan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China
| | - Han Yan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China
| | - Shan Cao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China
| | - Xiao-Lin Li
- Department of Hematology, Xiang-Ya Hospital, Central South University, Changsha 410008, Hunan, PR China
| | - Hui Zeng
- Department of Hematology, Xiang-Ya Hospital, Central South University, Changsha 410008, Hunan, PR China
| | - Xiao-Ping Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, PR China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha 410078, Hunan, PR China.,Hunan Province Cooperation Innovation Center for Molecular Target New Drug Study, Hengyang 421001, Hunan, PR China
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40
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Brumatti G, Ma C, Lalaoui N, Nguyen NY, Navarro M, Tanzer MC, Richmond J, Ghisi M, Salmon JM, Silke N, Pomilio G, Glaser SP, de Valle E, Gugasyan R, Gurthridge MA, Condon SM, Johnstone RW, Lock R, Salvesen G, Wei A, Vaux DL, Ekert PG, Silke J. The caspase-8 inhibitor emricasan combines with the SMAC mimetic birinapant to induce necroptosis and treat acute myeloid leukemia. Sci Transl Med 2016; 8:339ra69. [DOI: 10.1126/scitranslmed.aad3099] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 04/04/2016] [Indexed: 12/13/2022]
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41
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Abstract
Acute myeloid leukaemia (AML) is a heterogeneous disease that is, in general, associated with a very poor prognosis. Multiple cytogenetic and molecular abnormalities that characterize different forms of AML have been used to better prognosticate patients and inform treatment decisions. Indeed, risk status in patients with this disease has classically been based on cytogenetic findings; however, additional molecular characteristics have been shown to inform risk assessment, including FLT3, NPM1, KIT, and CEBPA mutation status. Advances in sequencing technology have led to the discovery of novel somatic mutations in tissue samples from patients with AML, providing deeper insight into the mutational landscape of the disease. The majority of patients with AML (>97%) are found to have a clonal somatic abnormality on mutational profiling. Nevertheless, our understanding of the utility of mutation profiling in clinical practice remains incomplete and is continually evolving, and evidence-based approaches to application of these data are needed. In this Review, we discuss the evidence-base for integrating mutational data into treatment decisions for patients with AML, and propose novel therapeutic algorithms in the era of molecular medicine.
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Affiliation(s)
- Catherine C Coombs
- Leukemia Service, Department of Medicine, Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
- Weill Cornell Medical Center, 1300 York Avenue, New York, New York 10065, USA
| | - Ross L Levine
- Leukemia Service, Department of Medicine, Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
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42
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Bret C, Viziteu E, Kassambara A, Moreaux J. Identifying high-risk adult AML patients: epigenetic and genetic risk factors and their implications for therapy. Expert Rev Hematol 2016; 9:351-60. [PMID: 26761438 DOI: 10.1586/17474086.2016.1141673] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease at molecular level, in response to therapy and prognosis. The molecular landscape of AML is evolving with new technologies revealing complex panorama of genetic abnormalities where genomic instability and aberrations of epigenetic regulators play a key role in pathogenesis. The characterization of AML diversity has led to development of new personalized therapeutic strategies to improve outcome of the patients.
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Affiliation(s)
- Caroline Bret
- a Department of Biological Hematology , CHU Montpellier , Montpellier , France.,b Institute of Human Genetics, CNRS-UPR1142 , Montpellier F-34396 , France.,c University of Montpellier 1, UFR de Médecine , Montpellier , France
| | - Elena Viziteu
- b Institute of Human Genetics, CNRS-UPR1142 , Montpellier F-34396 , France
| | - Alboukadel Kassambara
- a Department of Biological Hematology , CHU Montpellier , Montpellier , France.,b Institute of Human Genetics, CNRS-UPR1142 , Montpellier F-34396 , France
| | - Jerome Moreaux
- a Department of Biological Hematology , CHU Montpellier , Montpellier , France.,b Institute of Human Genetics, CNRS-UPR1142 , Montpellier F-34396 , France.,c University of Montpellier 1, UFR de Médecine , Montpellier , France
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43
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Irving JAE. Towards an understanding of the biology and targeted treatment of paediatric relapsed acute lymphoblastic leukaemia. Br J Haematol 2015; 172:655-66. [PMID: 26568036 DOI: 10.1111/bjh.13852] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Acute lymphoblastic leukaemia is the most common childhood cancer and for those children who relapse, prognosis is poor and new therapeutic strategies are needed. Recurrent pathways implicated in relapse include RAS, JAK STAT, cell cycle, epigenetic regulation, B cell development, glucocorticoid response, nucleotide metabolism and DNA repair. Targeting these pathways is a rational therapeutic strategy and may deliver novel, targeted therapies into the clinic. Relapse often stems from a minor clone present at diagnosis and thus analysis of persisting leukaemia during upfront therapy may allow targeted drug intervention to prevent relapse.
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Affiliation(s)
- Julie A E Irving
- Newcastle Cancer Centre at the Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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44
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Is it time to change conventional consolidation chemotherapy for acute myeloid leukemia in CR1? Curr Opin Hematol 2015; 22:123-31. [PMID: 25594168 DOI: 10.1097/moh.0000000000000119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Choosing the most appropriate postremission therapy (PRT) for a patient with acute myeloid leukemia (AML) in first complete remission remains a challenging task. Factors such as risk for disease relapse, nonrelapse mortality associated with different PRT approaches, donor availability, prospects for salvage should disease relapse, and patient preference all affect PRT choice. RECENT FINDINGS New genetic markers refine AML risk stratification and identify patients within the 'classical' risk groups who may benefit from transplant-based or chemotherapy-based PRT. The use of minimal residual disease in first remission to guide PRT choice and the application of novel, targeted therapies have the potential to alter PRT approaches across AML risk groups. The advent of alternative donor sources, use of reduced intensity regimens, and improved supportive care all affect the availability and safety of transplant-based PRT and challenge the relevance of the older legacy 'donor/no-donor' genetically randomized trials. SUMMARY Genetic risk assessment, monitoring of minimal residual disease in first remission, use of targeted agents, and the newer transplant strategies all have the potential to 'personalize' PRT choice in the AML patient. The clinical value of these novel interventions awaits validation in prospective, risk-adapted clinical trials.
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45
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Valdivieso M, Corn BW, Dancey JE, Wickerham DL, Horvath LE, Perez EA, Urton A, Cronin WM, Field E, Lackey E, Blanke CD. The Globalization of Cooperative Groups. Semin Oncol 2015; 42:693-712. [PMID: 26433551 DOI: 10.1053/j.seminoncol.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The National Cancer Institute (NCI)-supported adult cooperative oncology research groups (now officially Network groups) have a longstanding history of participating in international collaborations throughout the world. Most frequently, the US-based cooperative groups work reciprocally with the Canadian national adult cancer clinical trial group, NCIC CTG (previously the National Cancer Institute of Canada Clinical Trials Group). Thus, Canada is the largest contributor to cooperative groups based in the United States, and vice versa. Although international collaborations have many benefits, they are most frequently utilized to enhance patient accrual to large phase III trials originating in the United States or Canada. Within the cooperative group setting, adequate attention has not been given to the study of cancers that are unique to countries outside the United States and Canada, such as those frequently associated with infections in Latin America, Asia, and Africa. Global collaborations are limited by a number of barriers, some of which are unique to the countries involved, while others are related to financial support and to US policies that restrict drug distribution outside the United States. This article serves to detail the cooperative group experience in international research and describe how international collaboration in cancer clinical trials is a promising and important area that requires greater consideration in the future.
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Affiliation(s)
- Manuel Valdivieso
- Division of Hematology/Oncology, University of Michigan; and SWOG, Executive Officer, Quality Assurance and International Initiatives, Ann Arbor, MI.
| | - Benjamin W Corn
- Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv, Israel; and Department of Radiation Oncology, Jefferson Medical College, Philadelphia, PA
| | - Janet E Dancey
- Director, NCIC Clinical Trials Group; Scientific Director Canadian Cancer Clinical Trials Network; Program Leader, High Impact Clinical Trials, Ontario Institute for Cancer Research; Professor of Oncology, Queen's University, Kingston, Ontario, Canada
| | - D Lawrence Wickerham
- Deputy Chairman, NRG Oncology, Pittsburgh, PA; Department of Human Oncology, Pittsburgh Campus, Drexel University School of Medicine; Allegheny Cancer Center at Allegheny General Hospital, Pittsburgh, PA
| | - L Elise Horvath
- Executive Officer, Alliance for Clinical Trials in Oncology, Chicago, IL
| | - Edith A Perez
- Deputy Director at Large, Mayo Clinic Cancer Center; Group Vice Chair, Alliance for Clinical Trials in Oncology; Hematology/Oncology and Cancer Biology Mayo Clinic, Jacksonville, FL
| | - Alison Urton
- Group Administrator, NCIC Clinical Trials Group, Queen's University, Kingston, Ontario, Canada
| | - Walter M Cronin
- Associate Director, NRG Oncology Statistics and Data Management Center (SDMC); Associate Director, Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Erica Field
- Project Specialist III, RTOG, Philadelphia, PA
| | - Evonne Lackey
- Coordinating Center Manager, SWOG Statistical Center, Seattle, WA
| | - Charles D Blanke
- Chair, SWOG; Department of Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University and Knight Cancer Institute, Portland, OR
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46
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Yu Y, Xie Y, Cao L, Yang L, Yang M, Lotze MT, Zeh HJ, Kang R, Tang D. The ferroptosis inducer erastin enhances sensitivity of acute myeloid leukemia cells to chemotherapeutic agents. Mol Cell Oncol 2015; 2:e1054549. [PMID: 27308510 DOI: 10.1080/23723556.2015.1054549] [Citation(s) in RCA: 291] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
Acute myeloid leukemia (AML) is the most common type of leukemia in adults. Development of resistance to chemotherapeutic agents is a major hurdle in the effective treatment of patients with AML. The quinazolinone derivative erastin was originally identified in a screen for small molecules that exhibit synthetic lethality with expression of the RAS oncogene. This lethality was subsequently shown to occur by induction of a novel form of cell death termed ferroptosis. In this study we demonstrate that erastin enhances the sensitivity of AML cells to chemotherapeutic agents in an RAS-independent manner. Erastin dose-dependently induced mixed types of cell death associated with ferroptosis, apoptosis, necroptosis, and autophagy in HL-60 cells (AML, NRAS_Q61L), but not Jurkat (acute T-cell leukemia, RAS wild type), THP-1 (AML, NRAS_G12D), K562 (chronic myelogenous leukemia, RAS wild type), or NB-4 (acute promyelocytic leukemia M3, KRAS_A18D) cells. Treatment with ferrostatin-1 (a potent ferroptosis inhibitor) or necrostatin-1 (a potent necroptosis inhibitor), but not with Z-VAD-FMK (a general caspase inhibitor) or chloroquine (a potent autophagy inhibitor), prevented erastin-induced growth inhibition in HL-60 cells. Moreover, inhibition of c-JUN N-terminal kinase and p38, but not of extracellular signal-regulated kinase activation, induced resistance to erastin in HL-60 cells. Importantly, low-dose erastin significantly enhanced the anticancer activity of 2 first-line chemotherapeutic drugs (cytarabine/ara-C and doxorubicin/adriamycin) in HL-60 cells. Collectively, the induction of ferroptosis and necroptosis contributed to erastin-induced growth inhibition and overcame drug resistance in AML cells.
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Affiliation(s)
- Yan Yu
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh; Pittsburgh, PA, USA; Department of Pediatrics; Xiangya Hospital; Central South University; Changsha, Hunan, China
| | - Yangchun Xie
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh ; Pittsburgh, PA, USA
| | - Lizhi Cao
- Department of Pediatrics; Xiangya Hospital; Central South University ; Changsha, Hunan, China
| | - Liangchun Yang
- Department of Pediatrics; Xiangya Hospital; Central South University ; Changsha, Hunan, China
| | - Minghua Yang
- Department of Pediatrics; Xiangya Hospital; Central South University ; Changsha, Hunan, China
| | - Michael T Lotze
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh ; Pittsburgh, PA, USA
| | - Herbert J Zeh
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh ; Pittsburgh, PA, USA
| | - Rui Kang
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh ; Pittsburgh, PA, USA
| | - Daolin Tang
- Center for DAMP Biology; Department of Surgery; University of Pittsburgh Cancer Institute; University of Pittsburgh ; Pittsburgh, PA, USA
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47
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Brendel C, Teichler S, Millahn A, Stiewe T, Krause M, Stabla K, Ross P, Huynh M, Illmer T, Mernberger M, Barckhausen C, Neubauer A. Oncogenic NRAS Primes Primary Acute Myeloid Leukemia Cells for Differentiation. PLoS One 2015; 10:e0123181. [PMID: 25901794 PMCID: PMC4406710 DOI: 10.1371/journal.pone.0123181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/17/2015] [Indexed: 11/18/2022] Open
Abstract
RAS mutations are frequently found among acute myeloid leukemia patients (AML), generating a constitutively active signaling protein changing cellular proliferation, differentiation and apoptosis. We have previously shown that treatment of AML patients with high-dose cytarabine is preferentially beneficial for those harboring oncogenic RAS. On the basis of a murine AML cell culture model, we ascribed this effect to a RAS-driven, p53-dependent induction of differentiation. Hence, in this study we sought to confirm the correlation between RAS status and differentiation of primary blasts obtained from AML patients. The gene expression signature of AML blasts with oncogenic NRAS indeed corresponded to a more mature profile compared to blasts with wildtype RAS, as demonstrated by gene set enrichment analysis (GSEA) and real-time PCR analysis of myeloid ecotropic viral integration site 1 homolog (MEIS1) in a unique cohort of AML patients. In addition, in vitro cell culture experiments with established cell lines and a second set of primary AML cells showed that oncogenic NRAS mutations predisposed cells to cytarabine (AraC) driven differentiation. Taken together, our findings show that AML with inv(16) and NRAS mutation have a differentiation gene signature, supporting the notion that NRAS mutation may predispose leukemic cells to AraC induced differentiation. We therefore suggest that promotion of differentiation pathways by specific genetic alterations could explain the superior treatment outcome after therapy in some AML patient subgroups. Whether a differentiation gene expression status may generally predict for a superior treatment outcome in AML needs to be addressed in future studies.
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Affiliation(s)
- Cornelia Brendel
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Sabine Teichler
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Axel Millahn
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Thorsten Stiewe
- Molecular Oncology, Philipps University of Marburg, Marburg, Germany
| | - Michael Krause
- Molecular Oncology, Philipps University of Marburg, Marburg, Germany
| | - Kathleen Stabla
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Petra Ross
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Minh Huynh
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Thomas Illmer
- Medical Clinic I, University Clinic of Technical University Dresden, Dresden, Germany
| | - Marco Mernberger
- Molecular Oncology, Philipps University of Marburg, Marburg, Germany
| | - Christina Barckhausen
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
| | - Andreas Neubauer
- Department of Hematology, Oncology and Immunology, Philipps University of Marburg, and University Clinic Giessen and Marburg, Marburg, Germany
- * E-mail:
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48
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Emerging diagnostic and therapeutic approaches in core binding factor acute myeloid leukaemia. Curr Opin Hematol 2015; 22:85-91. [DOI: 10.1097/moh.0000000000000124] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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49
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Bhatnagar B, Garzon R. The use of molecular genetics to refine prognosis in acute myeloid leukemia. Curr Hematol Malig Rep 2015; 9:148-57. [PMID: 24659319 DOI: 10.1007/s11899-014-0208-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The discovery and application of advanced molecular techniques, such as gene and microRNA expression profiling, whole genome and exome sequencing, proteomic analysis and methylation assays, have allowed for the identification of recurrent molecular abnormalities in acute myeloid leukemia (AML) that have revolutionized our understanding of the genetic landscape of the disease. These modalities have emerged as valuable tools that permit a more comprehensive and detailed molecular characterization of AML. Many of these molecular abnormalities have been shown to predict prognosis, particularly within the context of cytogenetically normal AML. This review will discuss the major techniques and platforms that have been used to identify novel recurrent gene mutations in AML and briefly describe how these discoveries have impacted on outcome prediction.
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50
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Azevedo MC, Velloso EDRP, Buccheri V, Chamone DAF, Dorlhiac-Llacer PE. Possible benefit of consolidation therapy with high-dose cytarabine on overall survival of adults with non-promyelocytic acute myeloid leukemia. Braz J Med Biol Res 2014; 48:178-85. [PMID: 25517921 PMCID: PMC4321225 DOI: 10.1590/1414-431x20144059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/10/2014] [Indexed: 01/09/2023] Open
Abstract
In adults with non-promyelocytic acute myeloid leukemia (AML), high-dose cytarabine
consolidation therapy has been shown to influence survival in selected patients,
although the appropriate doses and schemes have not been defined. We evaluated
survival after calculating the actual dose of cytarabine that patients received for
consolidation therapy and divided them into 3 groups according to dose. We conducted
a single-center, retrospective study involving 311 non-promyelocytic AML patients
with a median age of 36 years (16-79 years) who received curative treatment between
1978 and 2007. The 131 patients who received cytarabine consolidation were assigned
to study groups by their cytarabine dose protocol. Group 1 (n=69) received <1.5
g/m2 every 12 h on 3 alternate days for up to 4 cycles. The remaining
patients received high-dose cytarabine (≥1.5 g/m2 every 12 h on 3
alternate days for up to 4 cycles). The actual dose received during the entire
consolidation period in these patients was calculated, allowing us to divide these
patients into 2 additional groups. Group 2 (n=27) received an intermediate-high-dose
(<27 g/m2), and group 3 (n=35) received a very-high-dose (≥27
g/m2). Among the 311 patients receiving curative treatment, the 5-year
survival rate was 20.2% (63 patients). The cytarabine consolidation dose was an
independent determinant of survival in multivariate analysis; age, karyotype,
induction protocol, French-American-British classification, and de
novo leukemia were not. Comparisons showed that the risk of death was
higher in the intermediate-high-dose group 2 (hazard ratio [HR]=4.51; 95% confidence
interval [CI]: 1.81-11.21) and the low-dose group 1 (HR=4.43; 95% CI: 1.97-9.96) than
in the very-high-dose group 3, with no significant difference between those two
groups. Our findings indicated that very-high-dose cytarabine during consolidation in
adults with non-promyelocytic AML may improve survival.
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Affiliation(s)
- M C Azevedo
- Serviço de Hematologia, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - E D R P Velloso
- Serviço de Hematologia, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - V Buccheri
- Serviço de Hematologia, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - D A F Chamone
- Serviço de Hematologia, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - P E Dorlhiac-Llacer
- Serviço de Hematologia, Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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