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Khawaji ZY, Khawaji NY, Alahmadi MA, Elmoneim AA. Prediction of Response to FDA-Approved Targeted Therapy and Immunotherapy in Acute Lymphoblastic Leukemia (ALL). Curr Treat Options Oncol 2024:10.1007/s11864-024-01237-w. [PMID: 39102166 DOI: 10.1007/s11864-024-01237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 08/06/2024]
Abstract
OPINION STATEMENT Acute lymphoblastic leukemia (ALL) represents the predominant cancer in pediatric populations, though its occurrence in adults is relatively rare. Pre-treatment risk stratification is crucial for predicting prognosis. Important factors for assessment include patient age, white blood cell (WBC) count at diagnosis, extramedullary involvement, immunophenotype, and cytogenetic aberrations. Minimal residual disease (MRD), primarily assessed by flow cytometry following remission, plays a substantial role in guiding management plans. Over the past decade, significant advancements in ALL outcomes have been witnessed. Conventional chemotherapy has remarkably reduced mortality rates; however, its intensive nature raises safety concerns and has led to the emergence of treatment-resistant cases with recurrence of relapses. Consequently, The U.S. Food and Drug Administration (FDA) has approved several novel treatments for relapsed/refractory ALL due to their demonstrated efficacy, as indicated by improved complete remission and survival rates. These treatments include tyrosine kinase inhibitors (TKIs), the anti-CD19 monoclonal antibody blinatumomab, anti-CD22 inotuzumab ozogamicin, anti-CD20 rituximab, and chimeric antigen receptor (CAR) T-cell therapy. Identifying the variables that influence treatment decisions is a pressing necessity for tailoring therapy based on heterogeneous patient characteristics. Key predictive factors identified in various observational studies and clinical trials include prelymphodepletion disease burden, complex genetic abnormalities, and MRD. Furthermore, the development of serious adverse events following treatment could be anticipated through predictive models, allowing for appropriate prophylactic measures to be considered. The ultimate aim is to incorporate the concept of precision medicine in the field of ALL through valid prediction platform to facilitate the selection of the most suitable treatment approach.
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Affiliation(s)
| | | | | | - Abeer Abd Elmoneim
- Women and Child Health Department, Taibah University, Madinah, Kingdom of Saudi Arabia
- 2nd Affiliation: Pediatric Department, Faculty of Medicine, Sohag University, Sohag, Egypt
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2
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Chaudhary P, Chaudhary S, Patel F, Patel S, Vaishnani T, Trivedi N, Patel D, Sonagara T, Hirapara A, Vyas K, Patel L, Kumar R, Chakraborty N, Sharma D, Suthar J, Kamdar P, Jajodia E, Ahmad F, Arora N. Validation of a novel NGS based BCR::ABL1 kinase domain mutation detection assay in Indian cohort. Sci Rep 2024; 14:15745. [PMID: 38977756 PMCID: PMC11231265 DOI: 10.1038/s41598-024-66310-8] [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: 08/10/2023] [Accepted: 07/01/2024] [Indexed: 07/10/2024] Open
Abstract
The efficacy and treatment outcome of a CML patient are heavily dependent on BCR::ABL1 kinase domain (KD) mutation status. Next-generation sequencing technology is a bright alternative to the previously used sanger sequencing method due to its global presence in diagnostic setups, massive parallel sequencing ability, and far better sensitivity. In the present study, we have demonstrated a new protocol for kinase domain mutation analysis using the next-generation sequencing (NGS) method using the ion torrent sequencing platform. This protocol uses RNA as the starting material, followed by nested PCR to amplify the fusion transcript, which is subsequently used as a template for NGS. Initial validation and comparison of this assay with the sanger sequencing (SS) method yielded 95.23% agreement. CML samples (n = 121) with a failure to TKI response were subjected to this newly developed NGS-based assay to detect KD mutations, from which samples were found to have mutations with a sensitivity ranging from 2.32 to 93.41%. A total of 34.71% of samples (n = 42) were found to be positive for one or more KD mutations, whereas 65.29% of samples (n = 81) were found to be negative. Nine samples out of 42 positive samples, i.e., 21.42%, were found to have compound mutations. This is one of the first studies from India, which includes more than 160 samples and is analyzed by the NGS approach for KD mutation analysis.
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Affiliation(s)
- Pooja Chaudhary
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India.
| | - Spandan Chaudhary
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India.
| | - Falguni Patel
- Department of Biotechnology and Microbiology, Shri M.M. Patel Institute of Science and Research, Kadi Sarva Vishwavidyalaya, Gandhinagar, Gujarat, India
| | - Shiv Patel
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Toral Vaishnani
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Nikha Trivedi
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Dhiren Patel
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Tushar Sonagara
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Ashish Hirapara
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Kavisha Vyas
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Lokesh Patel
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Raja Kumar
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Nikkan Chakraborty
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Divya Sharma
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Jigar Suthar
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Payal Kamdar
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Ekta Jajodia
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Firoz Ahmad
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
| | - Neeraj Arora
- Molecular Department, Unipath Specialty Laboratory Ltd, Ahmedabad, Gujarat, India
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Seman ZA, Ahid F, Kamaluddin NR, Sahid ENM, Esa E, Said SSM, Azman N, Mat WKDW, Abdullah J, Ali NA, Khalid MKNM, Yusoff YM. Mutation analysis of BCR-ABL1 kinase domain in chronic myeloid leukemia patients with tyrosine kinase inhibitors resistance: a Malaysian cohort study. BMC Res Notes 2024; 17:111. [PMID: 38643202 PMCID: PMC11031984 DOI: 10.1186/s13104-024-06772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 04/15/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVE Mutational analysis of BCR::ABL1 kinase domain (KD) is a crucial component of clinical decision algorithms for chronic myeloid leukemia (CML) patients with failure or warning responses to tyrosine kinase inhibitor (TKI) therapy. This study aimed to detect BCR::ABL1 KD mutations in CML patients with treatment resistance and assess the concordance between NGS (next generation sequencing) and Sanger sequencing (SS) in detecting these mutations. RESULTS In total, 12 different BCR::ABL1 KD mutations were identified by SS in 22.6% (19/84) of patients who were resistant to TKI treatment. Interestingly, NGS analysis of the same patient group revealed an additional four different BCR::ABL1 KD mutations in 27.4% (23/84) of patients. These mutations are M244V, A344V, E355A, and E459K with variant read frequency below 15%. No mutation was detected in 18 patients with optimal response to TKI therapy. Resistance to TKIs is associated with the acquisition of additional mutations in BCR::ABL1 KD after treatment with TKIs. Additionally, the use of NGS is advised for accurately determining the mutation status of BCR::ABL1 KD, particularly in cases where the allele frequency is low, and for identifying mutations across multiple exons simultaneously. Therefore, the utilization of NGS as a diagnostic platform for this test is very promising to guide therapeutic decision-making.
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Affiliation(s)
- Zahidah Abu Seman
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
- Centre for Medical Laboratory Technology Studies, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, 42300, Malaysia
| | - Fadly Ahid
- Centre for Medical Laboratory Technology Studies, Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam, Selangor, 42300, Malaysia.
- Stem Cell and Regenerative Medicine Research Initiative Group, Universiti Teknologi MARA, Shah Alam, Selangor, 40450, Malaysia.
| | - Nor Rizan Kamaluddin
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Ermi Neiza Mohd Sahid
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Ezalia Esa
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Siti Shahrum Muhamed Said
- Department of Pathology, Hospital Tunku Azizah, Ministry of Health Malaysia, Kuala Lumpur, Kuala Lumpur, WP, 50300, Malaysia
| | - Norazlina Azman
- Department of Pathology, Hospital Tunku Azizah, Ministry of Health Malaysia, Kuala Lumpur, Kuala Lumpur, WP, 50300, Malaysia
| | - Wan Khairull Dhalila Wan Mat
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Julia Abdullah
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Nurul Aqilah Ali
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia
| | - Mohd Khairul Nizam Mohd Khalid
- Inborn Error of Metabolism and Genetic Unit, Metabolic & Cardiovascular Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Nutrition, Shah Alam, Selangor, 40170, Malaysia
| | - Yuslina Mat Yusoff
- Hematology Unit, Cancer Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, 40170, Malaysia.
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Su J, Fu C, Wang S, Chen X, Wang R, Shi H, Li J, Wang X. Screening and Activity Evaluation of Novel BCR-ABL/T315I Tyrosine Kinase Inhibitors. Curr Med Chem 2024; 31:2872-2894. [PMID: 37211852 DOI: 10.2174/0929867330666230519105900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Chronic myeloid leukemia (CML) is a kind of malignant tumor formed by the clonal proliferation of bone marrow hematopoietic stem cells. BCR-ABL fusion protein, found in more than 90% of patients, is a vital target for discovering anti- CML drugs. Up to date, imatinib is the first BCR-ABL tyrosine kinase inhibitor (TKI) approved by the FDA for treating CML. However, the drug resistance problems appeared for many reasons, especially the T135I mutation, a "gatekeeper" of BCR-ABL. Currently, there is no long-term effective and low side effect drug in clinical. METHODS This study intends to find novel TKIs targeting BCR-ABL with high inhibitory activity against T315I mutant protein by combining artificial intelligence technology and cell growth curve, cytotoxicity, flow cytometry and Western blot experiments. RESULTS The obtained compound was found to kill leukemia cells, which had good inhibitory efficacy in BaF3/T315I cells. Compound no 4 could induce cell cycle arrest, cause autophagy and apoptosis, and inhibit the phosphorylation of BCR-ABL tyrosine kinase, STAT5 and Crkl proteins. CONCLUSION The results indicated that the screened compound could be used as a lead compound for further research to discover ideal chronic myeloid leukemia therapeutic drugs.
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MESH Headings
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/metabolism
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/chemistry
- Humans
- Apoptosis/drug effects
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/chemistry
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Cell Proliferation/drug effects
- Drug Screening Assays, Antitumor
- Cell Line, Tumor
- Mice
- Animals
- Autophagy/drug effects
- STAT5 Transcription Factor/metabolism
- STAT5 Transcription Factor/antagonists & inhibitors
- Cell Cycle Checkpoints/drug effects
- Tyrosine Kinase Inhibitors
- Adaptor Proteins, Signal Transducing
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Affiliation(s)
- Jie Su
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Chenggong Fu
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Shuo Wang
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Xuelian Chen
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Runan Wang
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Huaihuai Shi
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Jiazhong Li
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
| | - Xin Wang
- School of Pharmacy, Lanzhou University, 199 West Donggang Rd., 730000, Lanzhou, China
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Yoshimaru R, Minami Y. Genetic Landscape of Chronic Myeloid Leukemia and a Novel Targeted Drug for Overcoming Resistance. Int J Mol Sci 2023; 24:13806. [PMID: 37762109 PMCID: PMC10530602 DOI: 10.3390/ijms241813806] [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: 06/28/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Tyrosine kinase inhibitors (TKIs) exemplify the success of molecular targeted therapy for chronic myeloid leukemia (CML). However, some patients do not respond to TKI therapy. Mutations in the kinase domain of BCR::ABL1 are the most extensively studied mechanism of TKI resistance in CML, but BCR::ABL1-independent mechanisms are involved in some cases. There are two known types of mechanisms that contribute to resistance: mutations in known cancer-related genes; and Philadelphia-associated rearrangements, a novel mechanism of genomic heterogeneity that occurs at the time of the Philadelphia chromosome formation. Most chronic-phase and accelerated-phase CML patients who were treated with the third-generation TKI for drug resistance harbored one or more cancer gene mutations. Cancer gene mutations and additional chromosomal abnormalities were found to be independently associated with progression-free survival. The novel agent asciminib specifically inhibits the ABL myristoyl pocket (STAMP) and shows better efficacy and less toxicity than other TKIs due to its high target specificity. In the future, pooled analyses of various studies should address whether additional genetic analyses could guide risk-adapted therapy and lead to a final cure for CML.
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Affiliation(s)
| | - Yosuke Minami
- Department of Hematology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-shi 277-8577, Japan;
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6
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Limsuwanachot N, Rerkamnuaychoke B, Niparuck P, Singdong R, Kongruang A, Hirunpatrawong P, Siriyakorn T, Yenchitsomanus PT, Siriboonpiputtana T. A customized mass array panel for BCR:: ABL1 tyrosine kinase domain mutation screening in chronic myeloid leukemia. J Mass Spectrom Adv Clin Lab 2023; 28:122-132. [PMID: 37128502 PMCID: PMC10148036 DOI: 10.1016/j.jmsacl.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/25/2023] [Accepted: 04/10/2023] [Indexed: 05/03/2023] Open
Abstract
Introduction The therapeutic strategy and management of chronic myeloid leukemia (CML) have rapidly improved with the discovery of effective tyrosine kinase inhibitors (TKIs) to target BCR::ABL1 oncoprotein. However, nearly 30% of patients develop TKI resistance due to acquired mutations on the tyrosine kinase domain (TKD) of BCR::ABL1. Methods We customized a mass array panel initially intended to detect and monitor the mutational burden of hotspot BCR::ABL1 TKD mutations accumulated in our database, including key mutations recently recommended by European LeukemiaNet. Additionally, we extended the feasibility of using the assay panel for the molecular classification of myeloproliferative neoplasms (MPNs) by incorporating primer sets specific for analyzing JAK2 V617F, MPL 515 K/L, and CALR types 1 and 2. Results We found that the developed mass array panel was superior for detecting and monitoring clinically significant BCR::ABL1 TKD mutations, especially in cases with low mutational burden and harboring compound/polyclonal mutations, compared with direct sequencing. Moreover, our customized mass array panel detected common genetic alterations in MPNs, and the findings were consistent with those of other comparable assays available in our laboratory. Conclusions Our customized mass array panel was practicably used as a routine robust assay for screening and monitoring BCR::ABL1 TKD mutations in patients with CML undergoing TKI treatment and feasible for analyzing common genetic mutations in MPNs.
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Affiliation(s)
- Nittaya Limsuwanachot
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Budsaba Rerkamnuaychoke
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimjai Niparuck
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Roongrudee Singdong
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Adcharee Kongruang
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Pa-thai Yenchitsomanus
- Siriraj Center of Research Excellence for Cancer Immunotherapy (SiCORE-CIT), Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Teerapong Siriboonpiputtana
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Corresponding author at: Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok 10400, Thailand.
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Koroleva OA, Dutikova YV, Trubnikov AV, Zenov FA, Manasova EV, Shtil AA, Kurkin AV. PROTAC: targeted drug strategy. Principles and limitations. Russ Chem Bull 2022; 71:2310-2334. [PMID: 36569659 PMCID: PMC9762658 DOI: 10.1007/s11172-022-3659-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/08/2022] [Accepted: 06/20/2022] [Indexed: 12/23/2022]
Abstract
The PROTAC (PROteolysis TArgeting Chimera) technology is a method of targeting intracellular proteins previously considered undruggable. This technology utilizes the ubiquitin-proteasome system in cells to specifically degrade target proteins, thereby offering significant advantages over conventional small-molecule inhibitors of the enzymatic function. Preclinical and preliminary clinical trials of PROTAC-based compounds (degraders) are presented. The review considers the general principles of the design of degraders. Advances and challenges of the PROTAC technology are discussed.
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Affiliation(s)
- O. A. Koroleva
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
| | - Yu. V. Dutikova
- Patent & Law Firm “A. Zalesov and Partners”, Build. 9, 2 ul. Marshala Rybalko, 123060 Moscow, Russian Federation
| | - A. V. Trubnikov
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
| | - F. A. Zenov
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
| | - E. V. Manasova
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
| | - A. A. Shtil
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
- N. N. Blokhin National Medical Research Center of Oncology, Ministry of Health of the Russian Federation, Build. 15, 24 Kashirskoe shosse, 115478 Moscow, Russian Federation
| | - A. V. Kurkin
- Department of Chemistry, Lomonosov Moscow State University, Build. 3, 1 Leninskie Gory, 119991 Moscow, Russian Federation
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Assanto GM, Scalzulli E, Carmosino I, Martelli M, Breccia M. From bench to bedside: bridging the gaps in best practices for real-world chronic myeloid leukemia care. Expert Rev Hematol 2022; 15:963-971. [PMID: 36305791 DOI: 10.1080/17474086.2022.2142112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although tyrosine kinase inhibitors (TKIs) determined an improvement of responses and overall survival (OS) in chronic phase chronic myeloid leukemia (CP-CML) patients, some patients still fail the achievement of important milestones. AREAS COVERED In this review, we focus on the need of appropriate molecular and mutational monitoring during TKI treatment with new laboratory tools and on new compounds developed to counteract the unmet clinical need in CP-CML. EXPERT OPINION The appropriate identification of BCR::ABL1 dependent and independent mechanisms of resistance with Next Generation Sequencing (NGS) and digital droplet PCR (ddPCR) can allow to improve the therapeutic strategies and prevent the onset of a failure to treatment. New compounds have been recently approved or are still in investigational trials to improve the response in some critical forms of resistance and/or intolerance to available TKIs.
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Affiliation(s)
- Giovanni Manfredi Assanto
- Department Cellular Biotechnol & Hematol, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Emilia Scalzulli
- Department Cellular Biotechnol & Hematol, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Ida Carmosino
- Department Cellular Biotechnol & Hematol, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Maurizio Martelli
- Department Cellular Biotechnol & Hematol, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
| | - Massimo Breccia
- Department Cellular Biotechnol & Hematol, Az. Policlinico Umberto I-Sapienza University, Rome, Italy
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Soverini S, De Santis S, Martelli M, Monaldi C, Castagnetti F, Gugliotta G, Papayannidis C, Mancini M, Bruno S, Venturi C, Machova Polakova K, Ernst T, Maar D, Corner A, Cavo M. Droplet digital PCR for the detection of second-generation tyrosine kinase inhibitor-resistant BCR::ABL1 kinase domain mutations in chronic myeloid leukemia. Leukemia 2022; 36:2250-2260. [PMID: 35908105 DOI: 10.1038/s41375-022-01660-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
Abstract
One of the indications for BCR::ABL1 mutation testing in chronic myeloid leukemia (CML) is when tyrosine kinase inhibitor therapy (TKI) needs to be changed for unsatisfactory response. In this study, we evaluated a droplet digital PCR (ddPCR)-based multiplex strategy for the detection and quantitation of transcripts harbouring mutations conferring resistance to second-generation TKIs (2GTKIs). Parallel quantitation of e13a2, e14a2 and e1a2 BCR::ABL1 fusion transcripts enables to express results as percentage of mutation positive- over total BCR::ABL1 transcripts. We determined the limit of blank in 60 mutation-negative samples. Accuracy was demonstrated by further analysis of 48 samples already studied by next generation sequencing (NGS). Mutations could be called down to 0.5% and across 3-logs of BCR::ABL1 levels. Retrospective review of BCR::ABL1 NGS results in 513 consecutive CML patients with non-optimal response to first- or second-line TKI therapy suggested that a ddPCR-based approach targeted against 2GTKI-resistant mutations would score samples as mutation-negative in 22% of patients with warning response to imatinib but only in 6% of patients with warning response to 2GTKIs. We conclude ddPCR represents an attractive method for easy, accurate and rapid screening for 2GTKI-resistant mutations impacting on TKI selection, although ddPCR cannot identify compound mutations.
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Affiliation(s)
- Simona Soverini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Università di Bologna, Bologna, Italy.
| | - Sara De Santis
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Università di Bologna, Bologna, Italy
| | - Margherita Martelli
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Università di Bologna, Bologna, Italy
| | - Cecilia Monaldi
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Università di Bologna, Bologna, Italy
| | - Fausto Castagnetti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Gabriele Gugliotta
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Manuela Mancini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Samantha Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Istituto di Ematologia "Seràgnoli", Università di Bologna, Bologna, Italy
| | - Claudia Venturi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | | | - Thomas Ernst
- Abteilung Hämatologie/Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Dianna Maar
- Bio-Rad Laboratories, Digital Biology Group, Pleasanton, CA, USA
| | - Adam Corner
- Bio-Rad Laboratories, Digital Biology Group, Peterborough, UK
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
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Fernandes A, Shanmuganathan N, Branford S. Genomic Mechanisms Influencing Outcome in Chronic Myeloid Leukemia. Cancers (Basel) 2022; 14:620. [PMID: 35158889 PMCID: PMC8833554 DOI: 10.3390/cancers14030620] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 02/01/2023] Open
Abstract
Chronic myeloid leukemia (CML) represents the disease prototype of genetically based diagnosis and management. Tyrosine kinase inhibitors (TKIs), that target the causal BCR::ABL1 fusion protein, exemplify the success of molecularly based therapy. Most patients now have long-term survival; however, TKI resistance is a persistent clinical problem. TKIs are effective in the BCR::ABL1-driven chronic phase of CML but are relatively ineffective for clinically defined advanced phases. Genomic investigation of drug resistance using next-generation sequencing for CML has lagged behind other hematological malignancies. However, emerging data show that genomic abnormalities are likely associated with suboptimal response and drug resistance. This has already been supported by the presence of BCR::ABL1 kinase domain mutations in drug resistance, which led to the development of more potent TKIs. Next-generation sequencing studies are revealing additional mutations associated with resistance. In this review, we discuss the initiating chromosomal translocation that may not always be a straightforward reciprocal event between chromosomes 9 and 22 but can sometimes be accompanied by sequence deletion, inversion, and rearrangement. These events may biologically reflect a more genomically unstable disease prone to acquire mutations. We also discuss the future role of cancer-related gene mutation analysis for risk stratification in CML.
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Affiliation(s)
- Adelina Fernandes
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology, Adelaide 5000, Australia; (A.F.); (N.S.)
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
- Precision Medicine Theme, South Australian Health & Medical Research Institute (SAHMRI), Adelaide 5000, Australia
| | - Naranie Shanmuganathan
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology, Adelaide 5000, Australia; (A.F.); (N.S.)
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
- Precision Medicine Theme, South Australian Health & Medical Research Institute (SAHMRI), Adelaide 5000, Australia
- Department of Haematology, Royal Adelaide Hospital and SA Pathology, Adelaide 5000, Australia
- School of Pharmacy and Medical Science, University of South Australia, Adelaide 5000, Australia
| | - Susan Branford
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology, Adelaide 5000, Australia; (A.F.); (N.S.)
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
- Precision Medicine Theme, South Australian Health & Medical Research Institute (SAHMRI), Adelaide 5000, Australia
- School of Pharmacy and Medical Science, University of South Australia, Adelaide 5000, Australia
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11
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De Santis S, Monaldi C, Mancini M, Bruno S, Cavo M, Soverini S. Overcoming Resistance to Kinase Inhibitors: The Paradigm of Chronic Myeloid Leukemia. Onco Targets Ther 2022; 15:103-116. [PMID: 35115784 PMCID: PMC8800859 DOI: 10.2147/ott.s289306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Protein kinases (PKs) play crucial roles in cellular proliferation and survival, hence their deregulation is a common event in the pathogenesis of solid and hematologic malignancies. Targeting PKs has been a promising strategy in cancer treatment, and there are now a variety of approved anticancer drugs targeting PKs. However, the phenomenon of resistance remains an obstacle to be addressed and overcoming resistance is a goal to be achieved. Chronic myeloid leukemia (CML) is the first as well as one of the best examples of a cancer that can be targeted by molecular therapy; hence, it can be used as a model disease for other cancers. This review aims to summarize up-to-date knowledge on the main mechanisms implicated in resistance to PK inhibitory therapies and to outline the main strategies that are being explored to overcome resistance. The importance of molecular diagnostics and disease monitoring in counteracting resistance will also be discussed.
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Affiliation(s)
- Sara De Santis
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, UO Ematologia ‘Lorenzo e Ariosto Seràgnoli’, Università di Bologna, Bologna, Italy
- Correspondence: Sara De Santis Insitute of Hematology “Lorenzo e Ariosto Seràgnoli”, Via Massarenti 9, Bologna, 40138, ItalyTel +39 051 2143791Fax +39 051 2144037 Email
| | - Cecilia Monaldi
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, UO Ematologia ‘Lorenzo e Ariosto Seràgnoli’, Università di Bologna, Bologna, Italy
| | - Manuela Mancini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Samantha Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, UO Ematologia ‘Lorenzo e Ariosto Seràgnoli’, Università di Bologna, Bologna, Italy
| | - Michele Cavo
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, UO Ematologia ‘Lorenzo e Ariosto Seràgnoli’, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Simona Soverini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, UO Ematologia ‘Lorenzo e Ariosto Seràgnoli’, Università di Bologna, Bologna, Italy
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12
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Easwar A, Siddon AJ. Genetic Landscape of Myeloproliferative Neoplasms with an Emphasis on Molecular Diagnostic Laboratory Testing. Life (Basel) 2021; 11:1158. [PMID: 34833034 PMCID: PMC8625510 DOI: 10.3390/life11111158] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 12/27/2022] Open
Abstract
Chronic myeloproliferative neoplasms (MPNs) are hematopoietic stem cell neoplasms with driver events including the BCR-ABL1 translocation leading to a diagnosis of chronic myeloid leukemia (CML), or somatic mutations in JAK2, CALR, or MPL resulting in Philadelphia-chromosome-negative MPNs with constitutive activation of the JAK-STAT signaling pathway. In the Philadelphia-chromosome-negative MPNs, modern sequencing panels have identified a vast molecular landscape including additional mutations in genes involved in splicing, signal transduction, DNA methylation, and chromatin modification such as ASXL1, SF3B1, SRSF2, and U2AF1. These additional mutations often influence prognosis in MPNs and therefore are increasingly important for risk stratification. This review focuses on the molecular alterations within the WHO classification of MPNs and laboratory testing used for diagnosis.
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Affiliation(s)
- Arti Easwar
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Alexa J. Siddon
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT 06510, USA;
- Department of Pathology, Yale School of Medicine, New Haven, CT 06510, USA
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13
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Sensitivity and reliability of DNA-based mutation analysis by allele-specific digital PCR to follow resistant BCR-ABL1-positive cells. Leukemia 2021; 35:2419-2423. [PMID: 33772144 DOI: 10.1038/s41375-021-01226-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/04/2021] [Accepted: 03/11/2021] [Indexed: 01/29/2023]
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14
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Benjamin ESB, Ravindra N, Rajamani BM, Anandan S, Kausalya B, Veldore V, Mathews V, Velayudhan SR, Balasubramanian P. BCR-ABL1 kinase domain mutation analysis by next generation sequencing detected additional mutations in chronic myeloid leukemia patients with suboptimal response to imatinib. Leuk Lymphoma 2021; 62:1528-1531. [PMID: 33478278 PMCID: PMC7611165 DOI: 10.1080/10428194.2021.1872074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | | | | | | | | | | | - Vikram Mathews
- Department of Hematology, Christian Medical College, Vellore, India
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15
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Leotta S, Markovic U, Pirosa MC, Stella S, Tringali S, Martino M, Specchia G, Carluccio P, Risitano AM, Grimaldi F, Vigna E, Palmieri F, Palmieri R, Annunziata M, Pisapia G, Palazzo G, Milone GA, Pelle AC, Scalise L, Di Giorgio MA, Bulla A, Leotta V, Di Raimondo F, Milone G. The role of ponatinib in adult BCR-ABL1 positive acute lymphoblastic leukemia after allogeneic transplantation: a real-life retrospective multicenter study. Ann Hematol 2021; 100:1743-1753. [PMID: 33774681 DOI: 10.1007/s00277-021-04504-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Abstract
The experience of third-generation tyrosine kinase inhibitor ponatinib treatment in Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph'+ ALL) patients post-allogeneic transplantation is limited. We retrospectively collected data on 25 Ph'+ ALL patients who were started on ponatinib after allogeneic transplantation between July 2015 and July 2019 from nine transplantation centers in Italy. Ponatinib was given in prophylaxis in five (20%), as pre-emptive treatment in seven (28%), and as salvage therapy in thirteen (52%) patients. It was combined with donor leukocyte infusions in ten patients. Half of the patients (12/25) harbored T315I mutation of BCR/ABL1, while in the remaining mutational analysis was negative or not performed. Among the 20 patients who received ponatinib as pre-emptive/salvage treatment, complete molecular response was achieved in 15 (75%) patients. Estimated overall survival at 2-year post-initiation of treatment in the whole cohort was 65% (respectively 60%, 60%, and 78% for the prophylaxis, pre-emptive, and salvage therapy groups). In patients with T315I-positive mutational status, the estimated 2-year survival was 40%. Fourteen patients (56%) experienced toxicity, requiring temporary or definitive suspension of treatment. In conclusion, treatment of Ph'+ ALL patients with ponatinib after transplantation is effective, although the question of adequate drug dose and treatment duration remains unanswered.
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Affiliation(s)
- Salvatore Leotta
- Divisione di Ematologia con Trapianto di midollo osseo - Azienda ospedaliero, universitaria Policlinico Vittorio Emanuele, Catania, Italy.
| | - Uros Markovic
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Maria Cristina Pirosa
- Divisione di Ematologia con Trapianto di midollo osseo - Azienda ospedaliero, universitaria Policlinico Vittorio Emanuele, Catania, Italy
| | - Stefania Stella
- Centro di Oncoematologia sperimentale, Università di Catania, Catania, Italy
| | - Stefania Tringali
- UOS Trapianto di midollo, Azienda ospedaliera Villa Sofia-Cervello, Palermo, Italy
| | - Massimo Martino
- Centro unico regionale trapianto cellule staminali e terapie cellulari A. Neri, Ospedale Bianchi - Melacrinò - Morelli, Reggio Calabria, Italy
| | - Giorgina Specchia
- Ematologia con trapianto - Azienda ospedaliero, universitaria Policlinico, Bari, Italy
| | - Paola Carluccio
- Ematologia con trapianto - Azienda ospedaliero, universitaria Policlinico, Bari, Italy
| | - Antonio M Risitano
- UOC di Ematologia e Trapianti di midollo - Azienda ospedaliero, universitaria Federico II, Naples, Italy
| | - Francesco Grimaldi
- UOC di Ematologia e Trapianti di midollo - Azienda ospedaliero, universitaria Federico II, Naples, Italy
| | - Ernesto Vigna
- Divisione di Ematologia, Azienda ospedaliera di Cosenza, Cosenza, Italy
| | - Fausto Palmieri
- Divisione di Ematologia, Azienda ospedaliera San Giuseppe Moscati, Avellino, Italy
| | - Raffaele Palmieri
- Divisione di Ematologia, Azienda ospedaliera San Giuseppe Moscati, Avellino, Italy
| | - Mario Annunziata
- Divisione di Ematologia, Azienda ospedaliera Cardarelli, Naples, Italy
| | - Giovanni Pisapia
- Divisione di Ematologia, Ospedale San Giuseppe Moscati, Taranto, Italy
| | - Giulia Palazzo
- Divisione di Ematologia, Ospedale San Giuseppe Moscati, Taranto, Italy
| | - Giulio Antonio Milone
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Angelo Curto Pelle
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Luca Scalise
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Mary Ann Di Giorgio
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Anna Bulla
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Valerio Leotta
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Francesco Di Raimondo
- Divisione di Ematologia con Trapianto di midollo osseo - Azienda ospedaliero, universitaria Policlinico Vittorio Emanuele, Catania, Italy.,Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania, Catania, Italy
| | - Giuseppe Milone
- Divisione di Ematologia con Trapianto di midollo osseo - Azienda ospedaliero, universitaria Policlinico Vittorio Emanuele, Catania, Italy
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16
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Soverini S, Bernardi S, Galimberti S. Molecular Testing in CML between Old and New Methods: Are We at a Turning Point? J Clin Med 2020; 9:E3865. [PMID: 33261150 PMCID: PMC7760306 DOI: 10.3390/jcm9123865] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 12/18/2022] Open
Abstract
Molecular monitoring of minimal residual disease (MRD) and BCR-ABL1 kinase domain (KD) mutation testing have a well consolidated role in the routine management of chronic myeloid leukemia (CML) patients, as they provide precious information for therapeutic decision-making. Molecular response levels are used to define whether a patient has an "optimal", "warning", or "failure" response to tyrosine kinase inhibitor (TKI) therapy. Mutation status may be useful to decide whether TKI therapy should be changed and which alternative TKI (or TKIs) are most likely to be effective. Real-time quantitative polymerase chain reaction (RQ-qPCR) and Sanger sequencing are currently the gold standard for molecular response monitoring and mutation testing, respectively. However, in recent years, novel technologies such as digital PCR (dPCR) and next-generation sequencing (NGS) have been evaluated. Here, we critically describe the main features of these old and novel technologies, provide an overview of the recently published studies assessing the potential clinical value of dPCR and NGS, and discuss how the state of the art might evolve in the next years.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Hematology/Oncology “Lorenzo e Ariosto Seràgnoli”, University of Bologna, 40138 Bologna, Italy;
| | - Simona Bernardi
- Department of Clinical and Experimental Sciences, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili, 25123 Brescia, Italy
- Centro di Ricerca Emato-Oncologica AIL (CREA), ASST Spedali Civili, 25123 Brescia, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, Hematology Unit, University of Pisa, 56126 Pisa, Italy;
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17
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Managing chronic myeloid leukemia for treatment-free remission: a proposal from the GIMEMA CML WP. Blood Adv 2020; 3:4280-4290. [PMID: 31869412 DOI: 10.1182/bloodadvances.2019000865] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022] Open
Abstract
Several papers authored by international experts have proposed recommendations on the management of BCR-ABL1+ chronic myeloid leukemia (CML). Following these recommendations, survival of CML patients has become very close to normal. The next, ambitious, step is to bring as many patients as possible into a condition of treatment-free remission (TFR). The Gruppo Italiano Malattie EMatologiche dell'Adulto (GIMEMA; Italian Group for Hematologic Diseases of the Adult) CML Working Party (WP) has developed a project aimed at selecting the treatment policies that may increase the probability of TFR, taking into account 4 variables: the need for TFR, the tyrosine kinase inhibitors (TKIs), the characteristics of leukemia, and the patient. A Delphi-like method was used to reach a consensus among the representatives of 50 centers of the CML WP. A consensus was reached on the assessment of disease risk (EUTOS Long Term Survival [ELTS] score), on the definition of the most appropriate age boundaries for the choice of first-line treatment, on the choice of the TKI for first-line treatment, and on the definition of the responses that do not require a change of the TKI (BCR-ABL1 ≤10% at 3 months, ≤1% at 6 months, ≤0.1% at 12 months, ≤0.01% at 24 months), and of the responses that require a change of the TKI, when the goal is TFR (BCR-ABL1 >10% at 3 and 6 months, >1% at 12 months, and >0.1% at 24 months). These suggestions may help optimize the treatment strategy for TFR.
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18
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Lewis M, Prouzet‐Mauléon V, Lichou F, Richard E, Iggo R, Turcq B, Mahon F. A genome-scale CRISPR knock-out screen in chronic myeloid leukemia identifies novel drug resistance mechanisms along with intrinsic apoptosis and MAPK signaling. Cancer Med 2020; 9:6739-6751. [PMID: 38831555 PMCID: PMC7520295 DOI: 10.1002/cam4.3231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/19/2022] Open
Abstract
Understanding resistance mechanisms in cancer is of utmost importance for the discovery of novel "druggable" targets. Efficient genetic screening, now even more possible with CRISPR-Cas9 gene-editing technology, next-generation sequencing and bioinformatics, is an important tool for deciphering novel cellular processes, such as resistance to treatment in cancer. Imatinib specifically eliminates chronic myeloid leukemia (CML) cells by targeting and blocking the kinase activity of BCR-ABL1; however, resistance to treatment exists. In order to discover BCR-ABL1 independent mechanisms of imatinib resistance, we utilized the genome-scale CRISPR knock-out library to screen for imatinib-sensitizing genes in vitro on K562 cells. We revealed genes that seem essential for imatinib-induced cell death, such as proapoptotic genes (BIM, BAX) or MAPK inhibitor SPRED2. Specifically, reestablishing apoptosis in BIM knock-out (KO) cells with BH3 mimetics, or inhibiting MAPK signaling in SPRED2 KO cells with MEK inhibitors restores sensitivity to imatinib. In this work, we discovered previously identified pathways and novel pathways that modulate response to imatinib in CML cell lines, such as the implication of the Mediator complex, mRNA processing and protein ubiquitinylation. Targeting these specific genetic lesions with combinational therapy can overcome resistance phenotypes and paves the road for the use of precision oncology.
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Affiliation(s)
- Matthieu Lewis
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - Valérie Prouzet‐Mauléon
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - Florence Lichou
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - Elodie Richard
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - Richard Iggo
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - Béatrice Turcq
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
| | - François‐Xavier Mahon
- Laboratory of Mammary and Leukemic OncogenesisInserm U1218 ACTIONUniversity of BordeauxBergonié Cancer InstituteBordeauxFrance
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19
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Prospective assessment of NGS-detectable mutations in CML patients with nonoptimal response: the NEXT-in-CML study. Blood 2020; 135:534-541. [PMID: 31877211 DOI: 10.1182/blood.2019002969] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/03/2019] [Indexed: 12/20/2022] Open
Abstract
In chronic myeloid leukemia (CML) patients, tyrosine kinase inhibitors (TKIs) may select for drug-resistant BCR-ABL1 kinase domain (KD) mutants. Although Sanger sequencing (SS) is considered the gold standard for BCR-ABL1 KD mutation screening, next-generation sequencing (NGS) has recently been assessed in retrospective studies. We conducted a prospective, multicenter study (NEXT-in-CML) to assess the frequency and clinical relevance of low-level mutations and the feasibility, cost, and turnaround times of NGS-based BCR-ABL1 mutation screening in a routine setting. A series of 236 consecutive CML patients with failure (n = 124) or warning (n = 112) response to TKI therapy were analyzed in parallel by SS and NGS in 1 of 4 reference laboratories. Fifty-one patients (22 failure, 29 warning) who were negative for mutations by SS had low-level mutations detectable by NGS. Moreover, 29 (27 failure, 2 warning) of 60 patients who were positive for mutations by SS showed additional low-level mutations. Thus, mutations undetectable by SS were identified in 80 out of 236 patients (34%), of whom 42 (18% of the total) had low-level mutations somehow relevant for clinical decision making. Prospective monitoring of mutation kinetics demonstrated that TKI-resistant low-level mutations are invariably selected if the patients are not switched to another TKI or if they are switched to a inappropriate TKI or TKI dose. The NEXT-in-CML study provides for the first time robust demonstration of the clinical relevance of low-level mutations, supporting the incorporation of NGS-based BCR-ABL1 KD mutation screening results in the clinical decision algorithms.
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20
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Hochhaus A, Breccia M, Saglio G, García-Gutiérrez V, Réa D, Janssen J, Apperley J. Expert opinion-management of chronic myeloid leukemia after resistance to second-generation tyrosine kinase inhibitors. Leukemia 2020; 34:1495-1502. [PMID: 32366938 PMCID: PMC7266739 DOI: 10.1038/s41375-020-0842-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/20/2022]
Abstract
Regardless of line of therapy, treatment goals in chronic phase chronic myeloid leukemia (CML) are: avoid progression to accelerated phase or blast crisis CML such that patients achieve a life expectancy comparable with that of the general population; avoid adverse events (AEs); and restore and maintain quality of life. The most important prognostic factor for achieving these goals is response to tyrosine kinase inhibitors (TKIs) at key milestones. For patients failing a TKI, a treatment change is mandatory to limit the risk of progression and death. There is currently no precise guideline for patients that fail a second-generation TKI, and there is a paucity of data to guide clinical decision making in this setting. There is, therefore, an unmet need for practical and actionable guidance on how to manage patients who fail a second-generation TKI. Although the term 'failure' includes patients failing for resistance or intolerance, the focus of this paper is failure of a second-generation TKI because of resistance. CML patients who fail their first second-generation TKI for true resistance need a more potent therapy. In these patients, the key issues to consider are the relative appropriateness of early allogeneic hematopoietic stem cell transplantation or the use of a further TKI. Selection of the next line of treatment after second-generation TKI resistance should be individualized and must be based on patient-specific factors including cytogenetics, mutation profile, comorbidities, age, previous history of AEs with prior TKI therapy, and risk profile for AEs on specific TKIs. This expert opinion paper is not in conflict with existing recommendations, but instead represents an evolution of previous notions, based on new data, insights, and clinical experience. We review the treatment options for patients resistant to second-generation TKI therapy and provide our clinical opinions and guidance on key considerations for treatment decision making.
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Affiliation(s)
- Andreas Hochhaus
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany.
| | | | | | | | | | - Jeroen Janssen
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, loc. VUMC, Amsterdam, The Netherlands
| | - Jane Apperley
- Hammersmith Hospital, Imperial College London, London, UK
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21
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Cumbo C, Anelli L, Specchia G, Albano F. Monitoring of Minimal Residual Disease (MRD) in Chronic Myeloid Leukemia: Recent Advances. Cancer Manag Res 2020; 12:3175-3189. [PMID: 32440215 PMCID: PMC7211966 DOI: 10.2147/cmar.s232752] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/23/2020] [Indexed: 12/14/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm caused by the BCR-ABL1 fusion gene generation as a consequence of the t(9;22)(q34;q11) rearrangement. The identification of the BCR-ABL1 transcript was of critical importance for both CML diagnosis and minimal residual disease (MRD) monitoring. In this review, we report the recent advances in the CML MRD monitoring based on RNA, DNA and protein analysis. The detection of the BCR-ABL1 transcript by the quantitative reverse-transcriptase polymerase chain reaction is the gold standard method, but other systems based on digital PCR or on GeneXpert technology have been developed. In the last years, DNA-based assays showed high sensitivity and specificity, and flow cytometric approaches for the detection of the BCR-ABL1 fusion protein have also been tested. Recently, new MRD monitoring systems based on the detection of molecular markers other than the BCR-ABL1 fusion were proposed. These approaches, such as the identification of CD26+ leukemic stem cells, microRNAs and mitochondrial DNA mutations, just remain preliminary and need to be implemented. In the precision medicine era, the constant improvement of the CML MRD monitoring practice could allow clinicians to choose the best therapeutic algorithm and a more accurate selection of CML patients eligible for the tyrosine kinase inhibitors discontinuation.
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Affiliation(s)
- Cosimo Cumbo
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari 70124, Italy
| | - Luisa Anelli
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari 70124, Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari 70124, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari 70124, Italy
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22
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Luciano L, Annunziata M, Attolico I, Di Raimondo F, Maggi A, Malato A, Martino B, Palmieri F, Pane F, Sgherza N, Specchia G. The multi-tyrosine kinase inhibitor ponatinib for chronic myeloid leukemia: Real-world data. Eur J Haematol 2020; 105:3-15. [PMID: 32145037 DOI: 10.1111/ejh.13408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/19/2022]
Abstract
Development of the highly selective targeted tyrosine kinase inhibitors (TKIs) has expanded the therapeutic options for chronic myeloid leukemia (CML). Patients undergoing TKI therapy should be closely monitored to ensure that the best therapeutic response and quality of life are achieved, and to control suboptimal responses and adverse events. Despite the high rate of response using current first-line TKIs, treatment failure may still occur, and resistance is considered a challenge in the treatment of patients with CML. The third-generation TKI, ponatinib, is a potent orally bioavailable pan BCR-ABL inhibitor that inhibits both wild-type and mutant BCR-ABL1 kinase, including the "gatekeeper" T315I mutation, which is resistant to all other currently available TKIs. This paper reviews the effectiveness, feasibility, and safety of ponatinib in the real-life clinical management of CML. Potential prognostic factors in identifying patients most likely to benefit from ponatinib treatment will be discussed, and case presentations illustrating situations encountered in real-life clinical practice are described. Ponatinib is effective in patients who have received prior TKIs in clinical studies as well as under real-life conditions. Nevertheless, the risk/benefit balance must be evaluated for each patient, particularly considering disease state, mutational status, treatment line, intolerance/resistance to prior TKIs, age, frailty, and specific comorbidities.
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Affiliation(s)
- Luigia Luciano
- Hematology - Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | | | | | - Francesco Di Raimondo
- Division of Hematology, AOU Policlinico-OVE, Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
| | | | - Alessandra Malato
- UOC di Ematologia con UTMO, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Bruno Martino
- Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Fausto Palmieri
- Department of Hematology, AORN, "S.G. Moscati", Avellino, Italy
| | - Fabrizio Pane
- Hematology - Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
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23
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Soverini S, Albano F, Bassan R, Fabbiano F, Ferrara F, Foà R, Olivieri A, Rambaldi A, Rossi G, Sica S, Specchia G, Venditti A, Barosi G, Pane F. Next-generation sequencing for BCR-ABL1 kinase domain mutations in adult patients with Philadelphia chromosome-positive acute lymphoblastic leukemia: A position paper. Cancer Med 2020; 9:2960-2970. [PMID: 32154668 PMCID: PMC7196068 DOI: 10.1002/cam4.2946] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/15/2020] [Accepted: 02/12/2020] [Indexed: 12/28/2022] Open
Abstract
Emergence of clones carrying point mutations in the BCR‐ABL1 kinase domain (KD) is a common mechanism of resistance to tyrosine kinase inhibitor (TKI)‐based therapies in Philadelphia chromosome‐positive (Ph+) acute lymphoblastic leukemia (ALL). Sanger sequencing (SS) is the most frequently used method for diagnostic BCR‐ABL1 KD mutation screening, but it has some limitations—it is poorly sensitive and cannot robustly identify compound mutations. Next‐generation sequencing (NGS) may overcome these problems. NSG is increasingly available and has the potential to become the method of choice for diagnostic BCR‐ABL1 KD mutation screening. A group discussion within an ad hoc constituted Panel of Experts has produced a series of consensus‐based statements on the potential value of NGS testing before and during first‐line TKI‐based treatment, in relapsed/refractory cases, before and after allo‐stem cell transplantation, and on how NGS results may impact on therapeutic decisions. A set of minimal technical and methodological requirements for the analysis and the reporting of results has also been defined. The proposals herein reported may be used to guide the practical use of NGS for BCR‐ABL1 KD mutation testing in Ph+ ALL.
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Affiliation(s)
- Simona Soverini
- Institute of Hematology "Lorenzo e Ariosto Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
| | - Renato Bassan
- Ospedale dell'Angelo, UOC Ematologia, Mestre-Venezia, Italy
| | | | | | - Robin Foà
- Division of Hematology University "Sapienza", Rome, Italy
| | - Attilio Olivieri
- Department of Hematology, Università Politecnica delle Marche, Ancona, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hemato-Oncology, University of Milan and Azienda Socio-Sanitaria Territoriale (ASST) Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Rossi
- Dipartimento di Oncologia Clinica, A.O. Spedali Civili, Brescia, Italy
| | - Simona Sica
- Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
| | - Adriano Venditti
- Dipartimento di Biomedicina e Prevenzione, Universitá Tor Vergata, Rome, Italy
| | | | - Fabrizio Pane
- U.O.C. Ematologia e Trapianti di Midollo Azienda Ospedaliera, Universitaria Federico II di Napoli, Naples, Italy
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24
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New approaches to molecular monitoring in CML (and other diseases). Blood 2020; 134:1578-1584. [PMID: 31533919 DOI: 10.1182/blood.2019000838] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/29/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic myeloid leukemia (CML) is the model cancer, demonstrating the clinical benefits of targeted therapy and the power of molecular diagnostics and monitoring. In CML, the BCR-ABL1 fusion gene and its companion messenger RNA offers a unique target differentiating cancer from the normal cell, affording the potential for very sensitive and specific assays. Because CML is such an ideal model, new methods are arising that should make testing in CML faster, more reliable, and reach a greater sensitivity. New ultrasensitive sequencing approaches, coupled with single-cell genomic approaches, further the study of measurable residual disease, clonal heterogeneity, and promise to make clinical trials more innovative and informative. These methods should be able to be transferred to other hematological and solid malignancies.
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25
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Minervini CF, Cumbo C, Orsini P, Anelli L, Zagaria A, Specchia G, Albano F. Nanopore Sequencing in Blood Diseases: A Wide Range of Opportunities. Front Genet 2020; 11:76. [PMID: 32140171 PMCID: PMC7043087 DOI: 10.3389/fgene.2020.00076] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/23/2020] [Indexed: 12/20/2022] Open
Abstract
The molecular pathogenesis of hematological diseases is often driven by genetic and epigenetic alterations. Next-generation sequencing has considerably increased our genomic knowledge of these disorders becoming ever more widespread in clinical practice. In 2012 Oxford Nanopore Technologies (ONT) released the MinION, the first long-read nanopore-based sequencer, overcoming the main limits of short-reads sequences generation. In the last years, several nanopore sequencing approaches have been performed in various "-omic" sciences; this review focuses on the challenge to introduce ONT devices in the hematological field, showing advantages, disadvantages and future perspectives of this technology in the precision medicine era.
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Affiliation(s)
| | | | | | | | | | | | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
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26
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Romzova M, Smitalova D, Tom N, Jurcek T, Culen M, Zackova D, Mayer J, Racil Z. Novel Illumina‐based next generation sequencing approach with one‐round amplification provides early and reliable detection of BCR‐ABL1 kinase domain mutations in chronic myeloid leukemia. Br J Haematol 2020; 189:469-474. [DOI: 10.1111/bjh.16382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Marianna Romzova
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
- Department of Biochemistry Faculty of Medicine Masaryk University Brno Czech Republic
| | - Dagmar Smitalova
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
- Department of Internal medicine, Hematology and Oncology Faculty of Medicine Masaryk University Brno Czech Republic
| | - Nikola Tom
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
| | - Tomas Jurcek
- Department of Internal medicine, Hematology and Oncology Faculty of Medicine Masaryk University Brno Czech Republic
- Internal Hematology and Oncology Clinic University Hospital Brno Brno Czech Republic
| | - Martin Culen
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
- Department of Internal medicine, Hematology and Oncology Faculty of Medicine Masaryk University Brno Czech Republic
- Internal Hematology and Oncology Clinic University Hospital Brno Brno Czech Republic
| | - Daniela Zackova
- Internal Hematology and Oncology Clinic University Hospital Brno Brno Czech Republic
| | - Jiri Mayer
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
- Department of Internal medicine, Hematology and Oncology Faculty of Medicine Masaryk University Brno Czech Republic
- Internal Hematology and Oncology Clinic University Hospital Brno Brno Czech Republic
| | - Zdenek Racil
- Department of Molecular Medicine Central European Institute of TechnologyMasaryk University Brno Czech Republic
- Internal Hematology and Oncology Clinic University Hospital Brno Brno Czech Republic
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27
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Feys T. Anticipate Your Next Move in Chronic Myeloid Leukaemia Patient Management. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10310682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Treatment decisions in chronic myeloid leukaemia (CML) are complex and require the evaluation of many factors at each stage of therapy. Many patients will become resistant or intolerant to the first and subsequent lines of tyrosine kinase inhibitors (TKI) they receive, requiring them to switch to a different TKI. Clinicians are faced with many considerations when choosing subsequent treatments and an important issue is how best to manage failure on a second-generation TKI. During an interactive and case-based, Incyte-sponsored, satellite symposium at the 2019 European Hematology Association (EHA) congress, Dr Janssen and Prof Apperley discussed the current best practices for managing patients failing imatinib or second-generation TKI, considering whether second-generation TKI should be used sequentially and the timing of the introduction of a third-generation TKI (ponatinib). Dr Soverini and Dr de Lavallade discussed how regular BCR-ABL response monitoring and mutational analysis are integral to CML patient management. They highlighted the clinical relevance of low-level mutations and the necessity to prevent clonal expansion of these TKI-resistant mutants, and the accumulation of additional mutations, by switching to an effective TKI in a timely manner.
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Affiliation(s)
- Tom Feys
- Ariez International, Bruges, Belgium
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28
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Fielding AK. Curing Ph+ ALL: assessing the relative contributions of chemotherapy, TKIs, and allogeneic stem cell transplant. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:24-29. [PMID: 31808885 PMCID: PMC6913432 DOI: 10.1182/hematology.2019000010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The understanding and treatment of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia have changed rapidly in the past 10 years. The outcome is equally as good as for Ph- disease, and with targeted tyrosine kinase inhibitor therapies in addition to chemotherapy, the novel immunotherapy approaches, and the extension of allogeneic hematopoietic stem cell transplant (allo-HCT) to older individuals, there is the potential to exceed this outcome. There is particular interest in reducing chemotherapy exposure and considering for whom allo-HCT can be avoided. However, the patient population that can help test these options in clinical trials is limited in number, and the available evidence is often derived from single-arm studies. This paper summarizes outcomes achieved with recent approaches to de novo Ph+ acute lymphoblastic leukemia in the postimatinib era and helps integrate all the available information to assist the reader to make informed choices for patients in an increasingly complex field.
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Soverini S, Abruzzese E, Bocchia M, Bonifacio M, Galimberti S, Gozzini A, Iurlo A, Luciano L, Pregno P, Rosti G, Saglio G, Stagno F, Tiribelli M, Vigneri P, Barosi G, Breccia M. Next-generation sequencing for BCR-ABL1 kinase domain mutation testing in patients with chronic myeloid leukemia: a position paper. J Hematol Oncol 2019; 12:131. [PMID: 31801582 PMCID: PMC6894351 DOI: 10.1186/s13045-019-0815-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/27/2019] [Indexed: 12/31/2022] Open
Abstract
BCR-ABL1 kinase domain (KD) mutation status is considered to be an important element of clinical decision algorithms for chronic myeloid leukemia (CML) patients who do not achieve an optimal response to tyrosine kinase inhibitors (TKIs). Conventional Sanger sequencing is the method currently recommended to test BCR-ABL1 KD mutations. However, Sanger sequencing has limited sensitivity and cannot always discriminate between polyclonal and compound mutations. The use of next-generation sequencing (NGS) is increasingly widespread in diagnostic laboratories and represents an attractive alternative. Currently available data on the clinical impact of NGS-based mutational testing in CML patients do not allow recommendations with a high grade of evidence to be prepared. This article reports the results of a group discussion among an ad hoc expert panel with the objective of producing recommendations on the appropriateness of clinical decisions about the indication for NGS, the performance characteristics of NGS platforms, and the therapeutic changes that could be applied based on the use of NGS in CML. Overall, these recommendations might be employed to inform clinicians about the practical use of NGS in CML.
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Affiliation(s)
- Simona Soverini
- Hematology/Oncology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy.
| | | | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Antonella Gozzini
- Department of Cellular Therapies and Transfusion Medicine, AOU Careggi, Florence, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Patrizia Pregno
- Hematology Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Gianantonio Rosti
- Hematology/Oncology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences of the University of Turin, Mauriziano Hospital, Turin, Italy
| | - Fabio Stagno
- Hematology Section and BMT Unit, Rodolico Hospital, AOU Policlinico-V. Emanuele, Catania, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation, Department of Medical Area, University of Udine, Udine, Italy
| | - Paolo Vigneri
- Department of Clinical and Experimental Medicine and Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Massimo Breccia
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
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30
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Bonifacio M, Stagno F, Scaffidi L, Krampera M, Di Raimondo F. Management of Chronic Myeloid Leukemia in Advanced Phase. Front Oncol 2019; 9:1132. [PMID: 31709190 PMCID: PMC6823861 DOI: 10.3389/fonc.2019.01132] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Management of chronic myeloid leukemia (CML) in advanced phases remains a challenge also in the era of tyrosine kinase inhibitors (TKIs) treatment. Cytogenetic clonal evolution and development of resistant mutations represent crucial events that limit the benefit of subsequent therapies in these patients. CML is diagnosed in accelerated (AP) or blast phase (BP) in <5% of patients, and the availability of effective treatments for chronic phase (CP) has dramatically reduced progressions on therapy. Due to smaller number of patients, few randomized studies are available in this setting and evidences are limited. Nevertheless, three main scenarios may be drawn: (a) patients diagnosed in AP are at higher risk of failure as compared to CP patients, but if they achieve optimal responses with frontline TKI treatment their outcome may be similarly favorable; (b) patients diagnosed in BP may be treated with TKI alone or with TKI together with conventional chemotherapy regimens, and subsequent transplant decisions should rely on kinetics of response and individual transplant risk; (c) patients in CP progressing under TKI treatment represent the most challenging population and they should be treated with alternative TKI according to the mutational profile, optional chemotherapy in BP patients, and transplant should be considered in suitable cases after return to second CP. Due to lack of validated and reliable markers to predict blast crisis and the still unsatisfactory results of treatments in this setting, prevention of progression by careful selection of frontline treatment in CP and early treatment intensification in non-optimal responders remains the main goal. Personalized evaluation of response kinetics could help in identifying patients at risk for progression.
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Affiliation(s)
| | - Fabio Stagno
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Francesco Di Raimondo
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
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Kizilors A, Crisà E, Lea N, Passera R, Mian S, Anwar J, Best S, Nicolini FE, Ireland R, Aldouri M, Pocock C, Corbett T, Gale R, Bart-Smith E, Weston-Smith S, Wykes C, Kulasekararaj A, Jackson S, Harrington P, McLornan D, Raj K, Pagliuca A, Mufti GJ, de Lavallade H. Effect of low-level BCR-ABL1 kinase domain mutations identified by next-generation sequencing in patients with chronic myeloid leukaemia: a population-based study. LANCET HAEMATOLOGY 2019; 6:e276-e284. [PMID: 31036317 DOI: 10.1016/s2352-3026(19)30027-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/12/2019] [Accepted: 02/12/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Kinase domain mutations in BCR-ABL1 are associated with resistance to tyrosine kinase inhibitors in patients with chronic myeloid leukaemia. Next-generation sequencing (NGS) allows detection of low-level kinase domain mutations, but its relevance in clinical practice remains debated. We aimed to examine the clinical effects of low-level kinase domain mutations identified using NGS in patients with chronic myeloid leukaemia. METHODS In this population-based study, we included consecutive patients newly diagnosed with chronic myeloid leukaemia treated with first-line tyrosine kinase inhibitors, and patients identified at the time of resistance to first-line treatment with imatinib at six institutions (teaching hospitals and district hospitals) in southeast England. We screened patients for BCR-ABL1 kinase domain mutations using NGS, irrespective of patient response to tyrosine kinase inhibitor therapy. When we detected a mutation with NGS, we retrospectively analysed all previous samples to establish the date of first occurrence and subsequent kinetics of the mutant subclone (or subclones). The primary endpoints of this study were progression-free and event-free survival at 5 years. FINDINGS Between Feb 1, 2007, and Dec 31, 2014, we screened 121 patients with chronic myeloid leukaemia for BCR-ABL1 kinase domain mutation. 99 consecutive patients were newly diagnosed, with available sequential RNA stored. The remaining 22 patients were diagnosed between June 1, 1999, and June 30, 2006, and were screened at the time of resistance to first-line treatment with imatinib. Imatinib was the first-line treatment for 111 patients, nilotinib for seven patients, and dasatinib for three patients. We detected a kinase domain mutation in 25 (21%) of 121 patients. Low-level kinase domain mutations were first identified in 17 (68%) of 25 patients with mutation. For patients with a complete cytogenetic response, 13 (14%) of 93 patients screened had a mutation. Five (71%) of the seven patients with a clinically relevant mutation lost complete cytogenetic response compared with 15 (17%) of 86 patients without a clinically relevant mutation (80 patients without mutation and six patients with a tyrosine kinase inhibitor-sensitive mutation, p=0·0031). Patients harbouring a mutant clone had poorer 5-year progression-free survival (65·3% [95% CI 40·5-81·8] vs 86·9% [75·8-93·2]; p=0·0161) and poorer 5-year event-free survival (22·2% [CI 5·6-45·9] vs 62·0% [50·4-71·6]; p<0·0001) than did patients without a mutation. We identified a kinase domain mutation in four (10%) of 41 patients with samples available at 3 months after starting first-line tyrosine kinase inhibitor treatment; all four subsequently progressed to accelerated phase disease compared with only three (8%) of 37 without a mutation (p<0·0001). INTERPRETATION NGS reliably and consistently detected early appearance of kinase domain mutations that would not otherwise be detected by Sanger sequencing. For the first time, to our knowledge, we report the presence of kinase domain mutations after only 3 months of therapy, which could have substantial clinical implications. NGS will allow early clinical intervention and our findings will contribute to the establishment of new recommendations on the frequency of kinase domain mutation analysis to improve patient clinical care. FUNDING None.
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Affiliation(s)
- Aytug Kizilors
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Elena Crisà
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK; Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Nicholas Lea
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Roberto Passera
- Nuclear Medicine Division, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Syed Mian
- Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Jamal Anwar
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Steve Best
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Robin Ireland
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Maadh Aldouri
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematology, Medway Maritime Hospital, Gillingham, UK
| | | | - Tim Corbett
- Department of Haematology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Gale
- Department of Haematology, Maidstone and Tunbridge Wells Hospitals, Maidstone, UK
| | - Emily Bart-Smith
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Simon Weston-Smith
- Department of Haematology, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | - Clare Wykes
- Department of Haematology, Maidstone and Tunbridge Wells Hospitals, Maidstone, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Sophie Jackson
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Patrick Harrington
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Donal McLornan
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Kavita Raj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK
| | - Hugues de Lavallade
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Department of Haematological Medicine, King's College London School of Medicine, London, UK.
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[Recommendations from the French CML Study Group (Fi-LMC) for BCR-ABL1 kinase domain mutation analysis in chronic myeloid leukemia]. Bull Cancer 2019; 107:113-128. [PMID: 31353136 DOI: 10.1016/j.bulcan.2019.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 11/22/2022]
Abstract
In the context of chronic myeloid leukemia (CML) resistant to tyrosine kinase inhibitors (TKIs), BCR-ABL1 tyrosine kinase domain (TKD) mutations still remain the sole biological marker that directly condition therapeutic decision. These recommendations aim at updating the use of BCR-ABL1 mutation testing with respect to new available therapeutic options and at repositioning different testing methods at the era of next generation sequencing (NGS). They have been written by a panel of experts from the French Study Group on CML (Fi-LMC), after a critical review of relevant publications. TKD mutation testing is recommended in case of treatment failure but not in case of optimal response. For patients in warning situation, mutation testing must be discussed depending on the type of TKI used, lasting of the treatment, kinetic evolution of BCR-ABL1 transcripts along time and necessity for switching treatment. The kind and the frequency of TKD mutations occasioning resistance mainly depend on the TKI in use and disease phase. Because of its better sensitivity, NGS methods are recommended for mutation testing rather than Sanger's. Facing a given TKD mutation, therapeutic decision should be taken based on in vitro sensitivity and clinical efficacy data. Identification by sequencing of a TKD mutation known to induce resistance must lead to a therapeutic change. The clinical value of testing methods more sensitive than NGS remains to be assessed.
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Soverini S, Martelli M, Bavaro L. BCR-ABL1 mutation screening in chronic myeloid leukaemia: is next now? LANCET HAEMATOLOGY 2019; 6:e236-e237. [DOI: 10.1016/s2352-3026(19)30046-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/27/2022]
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陈 晨, 许 娜, 江 雪, 吴 婉, 周 璇, 刘 靓, 黄 继, 阴 常, 曹 睿, 廖 立, 徐 丹, 张 宇, 刘 启, 刘 晓. [Clinical characteristics of chronic myeloid leukemia with T315I mutation and the efficacy of ponatinib]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:364-368. [PMID: 31068313 PMCID: PMC6765683 DOI: 10.12122/j.issn.1673-4254.2019.03.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyze the clinical features of chronic myeloid leukemia (CML) with T315 I mutation (CML-T315I) and compare the effectiveness of different treatments. METHODS We retrospectively analyzed the clinical data and outcomes of 19 patients with CML-T315I receiving different treatments. The T315 I mutations in these patients were detected by examination of BCR-ABL kinase domain (KD) mutation by RTQ-PCR and Sanger sequencing. The relapse following the treatments, defined as hematological, cytogenetic and molecular biological recurrences, were analyzed in these patients. RESULTS Of the 19 patients with CML-T315I, 14 (73.7%) were in CML-CP stage at the initial diagnosis, and 13 (81.2%) were high-risk patients based on the Sokal scores. All the 19 patients were treated with TKI after the initial diagnosis, and during the treatment, 15 (78.9%) patients were found to have additional chromosomal aberrations, and 10 (52.6%) had multiple mutations; 13 (68.4%) of the patients experienced disease progression (accelerated phase/blast crisis) before the detection of T315I mutation, with a median time of 40 months (5-120 months) from the initial diagnosis to the mutation detection. After detection of the mutation, 12 patients were treated with ponatinib and 7 were managed with the conventional chemotherapy regimen, and their overall survival rates at 3 years were 83.3% and 14.2%, respectively (P < 0.001). CONCLUSIONS CML patients resistant to TKI are more likely to have T315I mutations, whose detection rate is significantly higher in the progressive phase than in the chronic phase. These patients often have additional chromosomal aberrations and multiple gene mutations with poor prognoses and a high recurrence rate even after hematopoietic stem cell transplantation. Long-term maintenance therapy with ponatinib may improve the prognosis and prolong the survival time of the patients.
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Affiliation(s)
- 晨 陈
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 娜 许
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 雪杰 江
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 婉儿 吴
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 璇 周
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 靓 刘
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 继贤 黄
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 常欣 阴
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 睿 曹
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 立斌 廖
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 丹 徐
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 宇明 张
- 广东医科大学附属医院血液科,广东 湛江 524000Department of Hematology, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524000, China
| | - 启发 刘
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 晓力 刘
- 南方医科大学南方医院血液科,广东 广州 510515Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Kang KH, Kim SH, Choi SY, Yoo HL, Lee MY, Song HY, Kee KM, Suh JH, Yang SY, Jang EJ, Lee SE, Kim DW. Compound mutations involving T315I and P-loop mutations are the major components of multiple mutations detected in tyrosine kinase inhibitor resistant chronic myeloid leukemia. Leuk Res 2018; 76:87-93. [PMID: 30503643 DOI: 10.1016/j.leukres.2018.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 12/22/2022]
Abstract
To analyze the pattern of multiple mutations detected by Sanger sequencing (SS), we performed subcloning sequencing using 218 samples from 45 patients with tyrosine kinase inhibitor resistant chronic myeloid leukemia. At the first time of multiple mutation detection by SS (baseline), a total of 19 major mutations from 45 samples were detected; these mutations were found in the following order: T315I (68.9%), E255 K (33.3%), Y253H (13.3%), G250E (13.3%), and F317 L (11.1%). Subcloning sequencing of 900 baseline colonies identified 556 different mutant types, and 791 among the 900 were colonies with major mutations (87.9%). The mutations were found in the following order: T315I (36.4%), E255 K (16.2%), Y253H (7.0%), G250E (6.7%), M351 T (6.6%), and E255 V (5.3%). In subcloning sequencing with 4357 colonies of 218 serial samples, 2506 colonies (57.5%) had compound mutations, among which 2238 colonies (89.3%) had at least one major mutation. The median number of mutations in compound mutant colonies was 2 (range, 2-7), and most were double (52.9%) or triple (28.7%) mutations. Additionally, some mutations in allosteric binding sites were detected as low level mutation in 13 patients. With the available retrospective samples before baseline, subcloning sequencing identified low-level mutations of various frequencies (median, 10%) to be major mutations in 20 patients. Thus, compound mutations involving T315I and P-loop mutations were the major components of multiple mutations, and some low-level mutations with potential clinical significance were detected by subcloning sequencing. Hence, more sensitive sequencing assays are needed in patients with multiple mutations.
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Affiliation(s)
- Ki-Hoon Kang
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Hyun Kim
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Young Choi
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae-Lyun Yoo
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mi-Young Lee
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye-Young Song
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Mi Kee
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Hyung Suh
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seon-Young Yang
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Jung Jang
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Lee
- Catholic Hematology Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Wook Kim
- Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea; Catholic Hematology Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
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37
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Sandt C, Feraud O, Bonnet ML, Desterke C, Khedhir R, Flamant S, Bailey CG, Rasko JEJ, Dumas P, Bennaceur-Griscelli A, Turhan AG. Direct and rapid identification of T315I-Mutated BCR-ABL expressing leukemic cells using infrared microspectroscopy. Biochem Biophys Res Commun 2018; 503:1861-1867. [PMID: 30057314 DOI: 10.1016/j.bbrc.2018.07.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/20/2018] [Accepted: 07/24/2018] [Indexed: 01/07/2023]
Abstract
Despite the major success obtained by the use of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML), resistances to therapies occur due to mutations in the ABL-kinase domain of the BCR-ABL oncogene. Amongst these mutations, the "gatekeeper" T315I is a major concern as it renders leukemic cells resistant to all licenced TKI except Ponatinib. We report here that Fourier transform infrared (FTIR) microspectroscopy is a powerful methodology allowing rapid and direct identification of a spectral signature in single cells expressing T315I-mutated BCR-ABL. The specificity of this spectral signature is confirmed using a Dox-inducible T315I-mutated BCR-ABL-expressing human UT-7 cells as well as in murine embryonic stem cells. Transcriptome analysis of UT-7 cells expressing BCR-ABL as compared to BCR-ABL T315I clearly identified a molecular signature which could be at the origin of the generation of metabolic changes giving rise to the spectral signature. Thus, these results suggest that this new methodology can be applied to the identification of leukemic cells harbouring the T315I mutation at the single cell level and could represent a novel early detection tool of mutant clones. It could also be applied to drug screening strategies to target T315I-mutated leukemic cells.
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MESH Headings
- Animals
- Cell Line
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Mice
- Mutation
- Spectroscopy, Fourier Transform Infrared
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Affiliation(s)
| | | | | | | | | | | | - Charles G Bailey
- Gene and Stem Cell Therapy Program, Centenary Institute, University of Sydney, Locked Bag No 6, Newtown, NSW, 2042, Australia; Sydney Medical School, University of Sydney, 2006, NSW, Australia
| | - John E J Rasko
- Gene and Stem Cell Therapy Program, Centenary Institute, University of Sydney, Locked Bag No 6, Newtown, NSW, 2042, Australia; Sydney Medical School, University of Sydney, 2006, NSW, Australia; Cell and Molecular Therapies, Royal Prince Alfred Hospital, Camperdown, 2052, NSW, Australia
| | - Paul Dumas
- SOLEIL Synchrotron, Saint Aubin, 91192, Gif sur Yvette, France
| | - Annelise Bennaceur-Griscelli
- INSERM UMR_S_935, Campus CNRS, Villejuif, France; Department of Hematology, Paris Sud Hematology Institute, AP-HP Hôpital Paul Brousse, Villejuif, France; INGESTEM National Pluripotent Stem Cell Infrastructure, University Paris Sud 11, Villejuif, France
| | - Ali G Turhan
- INSERM UMR_S_935, Campus CNRS, Villejuif, France; Department of Hematology, Paris Sud Hematology Institute, AP-HP Hôpital Paul Brousse, Villejuif, France; INGESTEM National Pluripotent Stem Cell Infrastructure, University Paris Sud 11, Villejuif, France.
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38
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Ogawa M, Yokoyama K, Hirano M, Jimbo K, Ochi K, Kawamata T, Ohno N, Shimizu E, Yokoyama N, Yamaguchi R, Imoto S, Uchimaru K, Takahashi N, Miyano S, Imai Y, Tojo A. Different clonal dynamics of chronic myeloid leukaemia between bone marrow and the central nervous system. Br J Haematol 2017; 183:842-845. [PMID: 29265350 DOI: 10.1111/bjh.15065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Miho Ogawa
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Kazuaki Yokoyama
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Mitsuhito Hirano
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Koji Jimbo
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Kiyosumi Ochi
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Toyotaka Kawamata
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Nobuhiro Ohno
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Eigo Shimizu
- Laboratory of DNA Information Analysis, Human Genome Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Nozomi Yokoyama
- Department of Applied Genomics, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Rui Yamaguchi
- Laboratory of DNA Information Analysis, Human Genome Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Seiya Imoto
- Division of Health Medical Data Science, Health Intelligence Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Kaoru Uchimaru
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan.,Laboratory of Tumour Cell Biology, Department of Computational Biology and Medical Science, Graduate School of Frontier Sciences, University of Tokyo, Tokyo, Japan
| | - Naoto Takahashi
- Department of Haematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Satoru Miyano
- Laboratory of DNA Information Analysis, Human Genome Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Yoichi Imai
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Department of Haematology/Oncology, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan.,Division of Molecular Therapy, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
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39
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Galimberti S, Bucelli C, Arrigoni E, Baratè C, Grassi S, Ricci F, Guerrini F, Ciabatti E, Fava C, D'Avolio A, Fontanelli G, Cambrin GR, Isidori A, Loscocco F, Caocci G, Greco M, Bocchia M, Aprile L, Gozzini A, Scappini B, Cattaneo D, Scortechini AR, La Nasa G, Bosi A, Leoni P, Danesi R, Saglio G, Visani G, Cortelezzi A, Petrini M, Iurlo A, Di Paolo A. The hOCT1 and ABCB1 polymorphisms do not influence the pharmacodynamics of nilotinib in chronic myeloid leukemia. Oncotarget 2017; 8:88021-88033. [PMID: 29152138 PMCID: PMC5675690 DOI: 10.18632/oncotarget.21406] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 08/29/2017] [Indexed: 11/25/2022] Open
Abstract
First-line nilotinib in chronic myeloid leukemia is more effective than imatinib to achieve early and deep molecular responses, despite poor tolerability or failure observed in one-third of patients. The toxicity and efficacy of tyrosine kinase inhibitors might depend on the activity of transmembrane transporters. However, the impact of transporters genes polymorphisms in nilotinib setting is still debated. We investigated the possible correlation between single nucleotide polymorphisms of hOCT1 (rs683369 [c.480C>G]) and ABCB1 (rs1128503 [c.1236C>T], rs2032582 [c.2677G>T/A], rs1045642 [c.3435C>T]) and nilotinib efficacy and toxicity in a cohort of 78 patients affected by chronic myeloid leukemia in the context of current clinical practice. The early molecular response was achieved by 81% of patients while 64% of them attained deep molecular response (median time, 26 months). The 36-month event-free survival was 86%, whereas 58% of patients experienced toxicities. Interestingly, hOCT1 and ABCB1 polymorphisms alone or in combination did not influence event-free survival or the adverse events rate. Therefore, in contrast to data obtained in patients treated with imatinib, hOCT1 and ABCB1 polymorphisms do not impact on nilotinib efficacy or toxicity. This could be relevant in the choice of the first-line therapy: patients with polymorphisms that negatively condition imatinib efficacy might thus receive nilotinib as first-line therapy.
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Affiliation(s)
- Sara Galimberti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Cristina Bucelli
- Oncohematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, University of Milan, Milano, Italy
| | - Elena Arrigoni
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Pisa, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Susanna Grassi
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy.,GeNOMEC, University of Siena, Siena, Italy
| | - Federica Ricci
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Francesca Guerrini
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Elena Ciabatti
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Carmen Fava
- Hematology Division, Ospedale Mauriziano, Torino, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giulia Fontanelli
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Giovanna Rege Cambrin
- Department of Clinical and Biological Sciences, University of Torino, AOU San Luigi Gonzaga, Torino, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, San Salvatore Hospital, Pesaro, Italy
| | - Federica Loscocco
- Hematology and Stem Cell Transplant Center, San Salvatore Hospital, Pesaro, Italy
| | - Giovanni Caocci
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - Marianna Greco
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - Monica Bocchia
- Division of Hematology, Ospedale Le Scotte, University of Siena, Siena, Italy
| | - Lara Aprile
- Division of Hematology, Ospedale Le Scotte, University of Siena, Siena, Italy
| | - Antonella Gozzini
- Division of Hematology, AOU Careggi, University of Florence, Firenze, Italy
| | - Barbara Scappini
- Division of Hematology, AOU Careggi, University of Florence, Firenze, Italy
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, University of Milan, Milano, Italy
| | | | - Giorgio La Nasa
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - Alberto Bosi
- Division of Hematology, AOU Careggi, University of Florence, Firenze, Italy
| | - Pietro Leoni
- Division of Hematology, Marche Polytechnic University, Ancona, Italy
| | - Romano Danesi
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Pisa, Italy
| | | | - Giuseppe Visani
- Hematology and Stem Cell Transplant Center, San Salvatore Hospital, Pesaro, Italy
| | - Agostino Cortelezzi
- Oncohematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, University of Milan, Milano, Italy
| | - Mario Petrini
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Alessandra Iurlo
- Oncohematology Division, IRCCS Ca' Granda, Maggiore Policlinico Hospital Foundation, University of Milan, Milano, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Pisa, Italy
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Ponatinib as a Valid Alternative Strategy in Patients with Blast Crisis-Chronic Myeloid Leukemia Not Eligible for Allogeneic Stem Cells Transplantation and/or Conventional Chemotherapy: Report of a Case. Case Rep Hematol 2017; 2017:6167345. [PMID: 28890835 PMCID: PMC5584354 DOI: 10.1155/2017/6167345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/19/2017] [Accepted: 07/12/2017] [Indexed: 01/07/2023] Open
Abstract
Currently, imatinib and dasatinib are the only tyrosine-kinase inhibitors approved in the US and Europe for the treatment of blast crisis of chronic myeloid leukemia (BC-CML) at diagnosis, while ponatinib is the only inhibitor used in patients bearing T315I mutation. Here we report the case of a 61-year-old man diagnosed with B-cell lymphoid BC-CML, initially treated with imatinib 800 mg day and then with dasatinib 140 mg day because of intolerance. A complete cytogenetic response (CCyR) was achieved at three months; however, three months later a relapse was observed, and the T315I mutation was detected. Ponatinib 45 mg once daily was then started together with a short course of chemotherapy. Bone marrow evaluation after six months of therapy showed the regaining of CCyR, together with the achievement of a deep molecular response. However, one year from ponatinib start the patient experienced a new disease relapse; he was effectively treated with ponatinib and chemotherapy once again, but in the meanwhile an ischemic stroke was detected. This case report confirms the high efficacy of ponatinib monotherapy in BC-CML patients, representing a valid option for non-allogeneic stem cells transplantation eligible cases and the only one available for those carrying the T315I mutation.
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41
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Minervini CF, Cumbo C, Orsini P, Anelli L, Zagaria A, Impera L, Coccaro N, Brunetti C, Minervini A, Casieri P, Tota G, Russo Rossi A, Specchia G, Albano F. Mutational analysis in BCR - ABL1 positive leukemia by deep sequencing based on nanopore MinION technology. Exp Mol Pathol 2017; 103:33-37. [DOI: 10.1016/j.yexmp.2017.06.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/22/2017] [Accepted: 06/25/2017] [Indexed: 01/11/2023]
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42
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Smith CIE. Enigmas in tumor resistance to kinase inhibitors and calculation of the drug resistance index for cancer (DRIC). Semin Cancer Biol 2016; 45:36-49. [PMID: 27865897 DOI: 10.1016/j.semcancer.2016.11.008] [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: 08/26/2016] [Accepted: 11/09/2016] [Indexed: 12/11/2022]
Abstract
Darwinian selection is also applicable when antibiotics, the immune system or other host factors shape the repertoire of microorganisms, and similarly, clonal selection is the hallmark of tumor evolution. The ongoing revolution in new anti-cancer treatment modalities, combined with an unprecedented precision in characterizing malignant clones at the level below one percent, profoundly improves the understanding of repertoire-tuning mechanisms. There is no fundamental difference between selection of the tumor cells in the presence, or absence, of therapy. However, under treatment the influence of a single agent can be measured, simplifying the analysis. Because of their beneficial and selective therapeutic effect, the focus in this review is set on protein kinase inhibitors (PKIs), predominantly tyrosine kinase inhibitors (TKIs). This is one of the most rapidly growing families of novel cancer medicines. In order to limit the number of drugs, the following representative target kinases are included: ALK, BCR-ABL, BRAF, BTK, and EGFR. A key therapeutic challenge is how to reduce tumor growth after treatment, since this is rate-limiting for the generation and expansion of more malignant escape mutants. Thus, upon efficient treatment, tumor cell loss often enables a profoundly increased growth rate among resistant cells. Strategies to reduce this risk, such as concomitant, competitive outgrowth of non-transformed cells, are described. Seven parameters: 1. Drug type, 2. tumor type, 3. presence of metastases or phenotypic change, 4. tumor cell number, 5. net growth rate (proliferation minus cell death), 6. inherited genetic- and 7. epigenetic- variations are crucial for drug responses. It is envisaged that it might become possible to calculate a clinically relevant Drug Resistance Index for Cancer (DRIC) for each patient.
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Affiliation(s)
- C I Edvard Smith
- Clinical Research Center, Dept. of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Huddinge, Sweden.
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43
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Soverini S, De Benedittis C, Castagnetti F, Gugliotta G, Mancini M, Bavaro L, Machova Polakova K, Linhartova J, Iurlo A, Russo D, Pane F, Saglio G, Rosti G, Cavo M, Baccarani M, Martinelli G. In chronic myeloid leukemia patients on second-line tyrosine kinase inhibitor therapy, deep sequencing of BCR-ABL1 at the time of warning may allow sensitive detection of emerging drug-resistant mutants. BMC Cancer 2016; 16:572. [PMID: 27485109 PMCID: PMC4970247 DOI: 10.1186/s12885-016-2635-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 07/27/2016] [Indexed: 11/15/2022] Open
Abstract
Background Imatinib-resistant chronic myeloid leukemia (CML) patients receiving second-line tyrosine kinase inhibitor (TKI) therapy with dasatinib or nilotinib have a higher risk of disease relapse and progression and not infrequently BCR-ABL1 kinase domain (KD) mutations are implicated in therapeutic failure. In this setting, earlier detection of emerging BCR-ABL1 KD mutations would offer greater chances of efficacy for subsequent salvage therapy and limit the biological consequences of full BCR-ABL1 kinase reactivation. Taking advantage of an already set up and validated next-generation deep amplicon sequencing (DS) assay, we aimed to assess whether DS may allow a larger window of detection of emerging BCR-ABL1 KD mutants predicting for an impending relapse. Methods a total of 125 longitudinal samples from 51 CML patients who had acquired dasatinib- or nilotinib-resistant mutations during second-line therapy were analyzed by DS from the time of failure and mutation detection by conventional sequencing backwards. BCR-ABL1/ABL1%IS transcript levels were used to define whether the patient had ‘optimal response’, ‘warning’ or ‘failure’ at the time of first mutation detection by DS. Results DS was able to backtrack dasatinib- or nilotinib-resistant mutations to the previous sample(s) in 23/51 (45 %) pts. Median mutation burden at the time of first detection by DS was 5.5 % (range, 1.5–17.5 %); median interval between detection by DS and detection by conventional sequencing was 3 months (range, 1–9 months). In 5 cases, the mutations were detectable at baseline. In the remaining cases, response level at the time mutations were first detected by DS could be defined as ‘Warning’ (according to the 2013 ELN definitions of response to 2nd-line therapy) in 13 cases, as ‘Optimal response’ in one case, as ‘Failure’ in 4 cases. No dasatinib- or nilotinib-resistant mutations were detected by DS in 15 randomly selected patients with ‘warning’ at various timepoints, that later turned into optimal responders with no treatment changes. Conclusions DS enables a larger window of detection of emerging BCR-ABL1 KD mutations predicting for an impending relapse. A ‘Warning’ response may represent a rational trigger, besides ‘Failure’, for DS-based mutation screening in CML patients undergoing second-line TKI therapy.
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Affiliation(s)
- Simona Soverini
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy. .,Institute of Hematology "L. e A. Seràgnoli", Via Massarenti 9, 40138, Bologna, Italy.
| | - Caterina De Benedittis
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Fausto Castagnetti
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Gabriele Gugliotta
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Luana Bavaro
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | | | - Jana Linhartova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Alessandra Iurlo
- Division of Haematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Russo
- Unit of Blood Disease and Stem Cell Transplantation, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fabrizio Pane
- Department of Biochemistry and Medical Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences "S. Luigi Gonzaga" Hospital, University of Turin, Orbassano, Italy
| | - Gianantonio Rosti
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Michele Cavo
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Michele Baccarani
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Hematology "L. e A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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