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Rohan P, Binato R, Abdelhay E. NF-ΚB Activation as a Key Driver in Chronic Lymphocytic Leukemia Evolution to Richter's Syndrome: Unraveling the Influence of Immune Microenvironment Dynamics. Genes (Basel) 2024; 15:1434. [PMID: 39596634 PMCID: PMC11593636 DOI: 10.3390/genes15111434] [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: 10/15/2024] [Revised: 10/30/2024] [Accepted: 10/31/2024] [Indexed: 11/29/2024] Open
Abstract
Background/Objectives: Chronic lymphocytic leukemia (CLL) is the most common adult leukemia in Western countries and it can progress to Richter's syndrome (RS), a more aggressive condition. The NF-κB pathway is pivotal in CLL pathogenesis, driven mainly by B-cell receptor (BCR) signaling. However, recent evidence indicates that BCR signaling is reduced in RS, raising questions about whether and how NF-κB activity is maintained in RS. This study aims to elucidate the triggers and dynamics of NF-κB activation and the progression from CLL to RS. Methods: Integrated single-cell RNA sequencing data from peripheral blood samples of four CLL-RS patients were analyzed. NF-κB pathway activity and gene expression profiles were assessed to determine changes in NF-κB components and their targets. Tumor microenvironment composition and cell-cell communication patterns were inferred to explore NF-κB regulatory mechanisms. Results: RS samples showed increased proportions of malignant cells expressing NF-κB components, including NFKB1, NFKB2, RELA, IKBKG, MAP3K14, CHUK, and IKBKB, with significantly higher expression levels than in CLL. Enhanced NF-κB pathway activity in RS cells was associated with targets involved in immune modulation. The tumor microenvironment in RS displayed significant compositional changes, and signaling inference revealed enhanced cell-cell communication via BAFF and APRIL pathways, involving interactions with receptors such as BAFF-R and TACI on RS cells. Conclusions: The findings from this study reveal an active state of NF-κB in RS and suggest that this state plays a critical role in the evolution of CLL to RS, which is modulated by alternative signaling pathways and the influence of the tumor microenvironment.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Tumor Microenvironment/genetics
- Tumor Microenvironment/immunology
- NF-kappa B/genetics
- NF-kappa B/metabolism
- Signal Transduction/genetics
- Receptors, Antigen, B-Cell/genetics
- Receptors, Antigen, B-Cell/metabolism
- Male
- Female
- Disease Progression
- Middle Aged
- Transcription Factor RelA/genetics
- Transcription Factor RelA/metabolism
- Single-Cell Analysis
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Affiliation(s)
| | | | - Eliana Abdelhay
- Stem Cell Laboratory, Specialized Laboratories Division, Instituto Nacional de Câncer (INCA), Rio de Janeiro 20230-130, RJ, Brazil; (P.R.); (R.B.)
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Wang K, Han S, Liu L, Zhao L, Herr I. Multi-Algorithm Analysis Reveals Pyroptosis-Linked Genes as Pancreatic Cancer Biomarkers. Cancers (Basel) 2024; 16:372. [PMID: 38254861 PMCID: PMC10814254 DOI: 10.3390/cancers16020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/09/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is often diagnosed at late stages, limiting treatment options and survival rates. Pyroptosis-related gene signatures hold promise as PDAC prognostic markers, but limited gene pools and small sample sizes hinder their utility. We aimed to enhance PDAC prognosis with a comprehensive multi-algorithm analysis. Using R, we employed natural language processing and latent Dirichlet allocation on PubMed publications to identify pyroptosis-related genes. We collected PDAC transcriptome data (n = 1273) from various databases, conducted a meta-analysis, and performed differential gene expression analysis on tumour and non-cancerous tissues. Cox and LASSO algorithms were used for survival modelling, resulting in a pyroptosis-related gene expression-based prognostic index. Laboratory and external validations were conducted. Bibliometric analysis revealed that pyroptosis publications focus on signalling pathways, disease correlation, and prognosis. We identified 357 pyroptosis-related genes, validating the significance of BHLHE40, IL18, BIRC3, and APOL1. Elevated expression of these genes strongly correlated with poor PDAC prognosis and guided treatment strategies. Our accessible nomogram model aids in PDAC prognosis and treatment decisions. We established an improved gene signature for pyroptosis-related genes, offering a novel model and nomogram for enhanced PDAC prognosis.
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Affiliation(s)
- Kangtao Wang
- Department of General, Visceral & Transplant Surgery, Molecular OncoSurgery, Section Surgical Research, University of Heidelberg, 69117 Heidelberg, Germany; (S.H.); (L.L.); (L.Z.); (I.H.)
- Department of General Surgery, The Xiangya Hospital, Central South University, Changsha 410008, China
| | - Shanshan Han
- Department of General, Visceral & Transplant Surgery, Molecular OncoSurgery, Section Surgical Research, University of Heidelberg, 69117 Heidelberg, Germany; (S.H.); (L.L.); (L.Z.); (I.H.)
| | - Li Liu
- Department of General, Visceral & Transplant Surgery, Molecular OncoSurgery, Section Surgical Research, University of Heidelberg, 69117 Heidelberg, Germany; (S.H.); (L.L.); (L.Z.); (I.H.)
| | - Lian Zhao
- Department of General, Visceral & Transplant Surgery, Molecular OncoSurgery, Section Surgical Research, University of Heidelberg, 69117 Heidelberg, Germany; (S.H.); (L.L.); (L.Z.); (I.H.)
| | - Ingrid Herr
- Department of General, Visceral & Transplant Surgery, Molecular OncoSurgery, Section Surgical Research, University of Heidelberg, 69117 Heidelberg, Germany; (S.H.); (L.L.); (L.Z.); (I.H.)
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Golyarnik N, Абраменко І, Movchan G, Martina Z, Dyagil I, Chumak A, Bazyka D. IMMUNOPHENOTYPE OF LEUKEMIC CELLS IN CHRONIC LYMPHOCYTIC LEUKEMIA PATIENTS WITH NOTCH1 AND SF3B1 GENE MUTATIONS. Exp Oncol 2023; 45:322-327. [PMID: 38186023 DOI: 10.15407/exp-oncology.2023.03.322] [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: 12/28/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND The typical chronic lymphocytic leukemia (CLL) immunophenotype is vital for diagnosis, but the expression of some antigens varies and has prognostic value. There are data that reduced CD20 expression is associated with NOTCH1 and SF3B1 gene mutations. AIM To determine a high-risk group of CLL patients for prediction of unfavorable NOTCH1 and SF3B1 gene mutations based on immunophenotyping of leukemic cells. MATERIALS AND METHODS Flow cytometric and molecular-genetic analysis (mutations of NOTCH1, SF3B1, and TP53 genes using the polymerase chain reaction followed by direct sequencing) was performed in a group of 86 previously untreated CLL patients. RESULTS The immunophenotype of leukemic cells of all examined patients met the criteria of CLL diagnosis. NOTCH1 gene mutations were found in 21 patients (24.4%), and SF3B1 gene mutations - in 7 patients (8.1%). There were no TP53 gene mutations among the examined patients. A decreased number of CD20+CD5+ cells and a downward trend in the relative index of mean fluorescence intensity (iMFI) of CD20+ cells were found in patients with NOTCH1 and SF3B1 gene mutations. Based on the iMFI level (higher and/or lower than 3.0) and the number of CD20+CD5+ cells among all B-cells (higher and/or lower than 50%), we distinguished CLL cases with low and relatively high levels of CD20 antigen expression. Using ROC analysis and the parameter of low CD20 antigen expression, we could predict the presence of NOTCH1 and SF3B1 gene mutations in 73.3 ± 0.06% of patients (p = 0.001). The risk of NOTCH1 and SF3B1 gene mutations in cases with low CD20 antigen expression was 6.96 (95% CI = 2.53-19.18; p = 0.0001). The revealed regularities were statistically significant for patients in whom the diagnosis was established in all Binet - Rai stages except A0-AI. CONCLUSION Our data confirmed a reduced CD20 expression in CLL patients with NOTCH1 and SF3B1 mutations. In addition, an approach was proposed to identify high-risk CLL patients for prediction of such mutations: previously untreated CLL patients at advanced Binet - Rai stages (BII, CIII, CIV) with a reduced number of double-positive CD20+CD5+ cells in peripheral blood and/or low iMFI of CD20+ cells.
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Affiliation(s)
- N Golyarnik
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - І Абраменко
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - G Movchan
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - Z Martina
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - I Dyagil
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - A Chumak
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - D Bazyka
- State Institution "National Research Center for Radiation Medicine, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
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Balla B, Tripon F, Candea M, Banescu C. Copy Number Variations and Gene Mutations Identified by Multiplex Ligation-Dependent Probe Amplification in Romanian Chronic Lymphocytic Leukemia Patients. J Pers Med 2023; 13:1239. [PMID: 37623489 PMCID: PMC10455273 DOI: 10.3390/jpm13081239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is known for its wide-ranging clinical and genetic diversity. The study aimed to assess the associations between copy number variations (CNVs) and various biological and clinical features, as well as the survival rates of CLL patients and to evaluate the effectiveness of the multiplex ligation-dependent probe amplification (MLPA) technique in CLL patients.DNA was extracted from 110 patients, and MLPA was performed. Mutations in NOTCH1, SF3B1, and MYD88 were also analyzed. A total of 52 patients showed at least one CNV, 26 had at least one somatic mutation, and 10 presented both, CNVs, and somatic mutations. The most commonly identified CNVs were del(114.3), del(11q22.3), and dup(12q23.2). Other CNVs identified included del(17p13.1), del(14q32.33), dup(10q23.31), and del(19p13.2). One patient was identified with concomitant trisomy 12, 13, and 19. NOTCH1 and SF3B1 mutations were found in 13 patients each, either alone or in combination with other mutations or CNVs, while MYD88 mutation was identified in one patient. Forty-two patients had normal results. Associations between the investigated CNVs and gene mutations and patients' overall survival were found. The presence of NOTCH1 and SF3B1 mutations or the combination of NOTCH1 mutation and CNVs significantly influenced the survival of patients with CLL. Both mutations are frequently associated with different CNVs. Del(13q) is associated with the longest survival rate, while the shortest survival is found in patients with del(17p). Even if MLPA has constraints, it may be used as the primary routine analysis in patients with CLL.
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Affiliation(s)
- Beata Balla
- Department of Medical Genetics, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (B.B.); (C.B.)
- Center for Advanced Medical and Pharmaceutical Research, Genetics Laboratory, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Florin Tripon
- Department of Medical Genetics, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (B.B.); (C.B.)
- Center for Advanced Medical and Pharmaceutical Research, Genetics Laboratory, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Marcela Candea
- Department of Internal Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania;
| | - Claudia Banescu
- Department of Medical Genetics, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (B.B.); (C.B.)
- Center for Advanced Medical and Pharmaceutical Research, Genetics Laboratory, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
- Medical Genetics Laboratory, Emergency County Hospital of Targu Mures, 540136 Targu Mures, Romania
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Ding YL, Li J, Yuan J, Wei Q, Li Y. Prognosis of a Chinese patient with chronic lymphocytic leukemia who acquired a TP53 mutation following treatment with a BTK inhibitor. Am J Transl Res 2023; 15:4813-4819. [PMID: 37560228 PMCID: PMC10408540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/05/2023] [Indexed: 08/11/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common type of adult leukemia that occurs in Western countries, and its incidence has gradually increased in China in recent years. The characteristics of CLL are highly heterogeneous. Despite promising response rates achieved with targeted therapy, new targets still need to be expanded due to the heterogeneous of disease. Bruton's tyrosine kinase inhibitor (BTKi) has been used in the treatment of TP53 mutation. In this report, we present a case with myeloid differentiation primary response 88 (MYD88) mutation who developed a TP53 mutation after application of BTKi. Here, the patient was CLL unmutated (U-CLL) with MYD88 (L265P) mutation before initial treatment. After traditional treatment, the effect was not good, and BTKi was used for treatment, then TP53 mutation appeared. It is well known that immunoglobulin heavy chain unmutated (IGHV-U) and TP53 mutation in CLL indicate poor prognosis. The case suggests that whenever TP53 mutation occurs, BTKi is the best choice. This result is considered to be related to signal pathways. We aim to add to the collective knowledge by highlighting this rare cases of CLL with MYD88 (L265P) mutation in an Asian patient.
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Affiliation(s)
- Yan-Ling Ding
- Department of Haematology, Hebei General HospitalShijiazhuang 050051, Hebei, The People’s Republic of China
- Department of Graduate School, Hebei North UniversityZhangjiakou 075000, Hebei, The People’s Republic of China
| | - Jie Li
- Department of Haematology, Hebei General HospitalShijiazhuang 050051, Hebei, The People’s Republic of China
| | - Jun Yuan
- Department of Haematology, Hebei General HospitalShijiazhuang 050051, Hebei, The People’s Republic of China
| | - Qiang Wei
- Department of Nuclear Medicine, Hebei General HospitalShijiazhuang 050051, Hebei, The People’s Republic of China
| | - Yan Li
- Department of Haematology, Hebei General HospitalShijiazhuang 050051, Hebei, The People’s Republic of China
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Zhang W, Long J, Tang P, Chen K, Guo G, Yu Z, Lin J, Liu L, Zhan R, Xu Z. SYT7 regulates the progression of chronic lymphocytic leukemia through interacting and regulating KNTC1. Biomark Res 2023; 11:58. [PMID: 37280656 DOI: 10.1186/s40364-023-00506-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is one of the most frequent occurring types of leukemia. It typically occurs in elderly patients and has a highly variable clinical course. At present, the molecular mechanism driving the pathogenesis and progression of CLL is not fully understood. The protein Synaptotagmin 7 (SYT7) encoded by the SYT7 gene has been found to be closely related to the development of various solid tumors, but its role in CLL is unclear. In this study, we investigated the function and molecular mechanism of SYT7 in CLL. METHODS The expression level of SYT7 in CLL was determined by immunohistochemical staining and qPCR. The role of SYT7 in promoting CLL development was verified by in vivo and in vitro experiments. The molecular mechanism of SYT7 in CLL was elucidated by methods such as GeneChip analysis and Co-immunoprecipitation assay. RESULTS Malignant behaviors such as proliferation, migration, and anti-apoptosis of CLL cells were significantly inhibited after SYT7 gene knockdown. In contrast, SYT7 overexpression promoted CLL development in vitro. Consistently, the knockdown of SYT7 also inhibited xenograft tumor growth of CLL cells. Mechanistically, SYT7 promoted CLL development by inhibiting SYVN1-mediated KNTC1 ubiquitination. The KNTC1 knockdown also attenuated the effects of SYT7 overexpression on development of CLL. CONCLUSIONS SYT7 regulates the progression of CLL through SYVN1-mediated KNTC1 ubiquitination, which has potential value for molecular targeted therapy of CLL.
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Affiliation(s)
- Wenjie Zhang
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Jinlan Long
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Peixia Tang
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Kaili Chen
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Guangyao Guo
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Zezhong Yu
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Jie Lin
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Liping Liu
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Rong Zhan
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China
| | - Zhenshu Xu
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, 29 Xinquan Rd, Fuzhou, 350001, China.
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O’Donnell A, Pepper C, Mitchell S, Pepper A. NF-kB and the CLL microenvironment. Front Oncol 2023; 13:1169397. [PMID: 37064123 PMCID: PMC10098180 DOI: 10.3389/fonc.2023.1169397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent type of leukemia in the western world. Despite the positive clinical effects of new targeted therapies, CLL still remains an incurable and refractory disease and resistance to treatments are commonly encountered. The Nuclear Factor-Kappa B (NF-κB) transcription factor has been implicated in the pathology of CLL, with high levels of NF-κB associated with disease progression and drug resistance. This aberrant NF-κB activation can be caused by genetic mutations in the tumor cells and microenvironmental factors, which promote NF-κB signaling. Activation can be induced via two distinct pathways, the canonical and non-canonical pathway, which result in tumor cell proliferation, survival and drug resistance. Therefore, understanding how the CLL microenvironment drives NF-κB activation is important for deciphering how CLL cells evade treatment and may aid the development of novel targeting therapeutics. The CLL microenvironment is comprised of various cells, including nurse like cells, mesenchymal stromal cells, follicular dendritic cells and CD4+ T cells. By activating different receptors, including the B cell receptor and CD40, these cells cause overactivity of the canonical and non-canonical NF-κB pathways. Within this review, we will explore the different components of the CLL microenvironment that drive the NF-κB pathway, investigating how this knowledge is being translated in the development of new therapeutics.
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Affiliation(s)
- Alice O’Donnell
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
- Royal Sussex County Hospital, University Hospitals Sussex, Brighton, United Kingdom
| | - Chris Pepper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Simon Mitchell
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Andrea Pepper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom
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Druggable Molecular Pathways in Chronic Lymphocytic Leukemia. Life (Basel) 2022; 12:life12020283. [PMID: 35207569 PMCID: PMC8875960 DOI: 10.3390/life12020283] [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: 12/24/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 12/02/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL), the most common type of leukemia in adults, is characterized by a high degree of clinical heterogeneity that is influenced by the disease’s molecular complexity. The genes most frequently affected in CLL cluster into specific biological pathways, including B-cell receptor (BCR) signaling, apoptosis, NF-κB, and NOTCH1 signaling. BCR signaling and the apoptosis pathway have been exploited to design targeted medicines for CLL therapy. Consistently, molecules that selectively inhibit specific BCR components, namely Bruton tyrosine kinase (BTK) and phosphoinositide 3-kinase (PI3K) as well as inhibitors of BCL2, have revolutionized the therapeutic management of CLL patients. Several BTK inhibitors and PI3K inhibitors with different modes of action are currently used or are in development in advanced stage clinical trials. Moreover, the restoration of apoptosis by the BCL2 inhibitor venetoclax offers meaningful clinical activity with a fixed-duration scheme. Inhibitors of the BCR and of BCL2 are able to overcome the chemorefractoriness associated with high-risk genetic features, including TP53 disruption. Other signaling cascades involved in CLL pathogenesis, in particular NOTCH signaling and NF-kB signaling, already provide biomarkers for a precision medicine approach to CLL and may represent potential druggable targets for the future. The aim of the present review is to discuss the druggable pathways of CLL and to provide the biological background of the high efficacy of targeted biological drugs in CLL.
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