1
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van de Loosdrecht AA, Cremers EMP, Alhan C, Duetz C, In 't Hout FEM, Visser-Wisselaar HA, Chitu DA, Verbrugge A, Cunha SM, Ossenkoppele GJ, Janssen JJWM, Klein SK, Vellenga E, Huls GA, Muus P, Langemeijer SMC, de Greef GE, Te Boekhorst PAW, Raaijmakers MHG, van Marwijk Kooy M, Legdeur MC, Wegman JJ, Deenik W, de Weerdt O, van Maanen-Lamme TM, Jobse P, van Kampen RJW, Beeker A, Wijermans PW, Biemond BJ, Tanis BC, van Esser JWJ, Schaar CG, Noordzij-Nooteboom HS, Jacobs EMG, de Graaf AO, Jongen-Lavrencic M, Stevens-Kroef MJPL, Westers TM, Jansen JH. Determinants of lenalidomide response with or without erythropoiesis-stimulating agents in myelodysplastic syndromes: the HOVON89 trial. Leukemia 2024; 38:840-850. [PMID: 38297135 PMCID: PMC10997501 DOI: 10.1038/s41375-024-02161-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
A randomized phase-II study was performed in low/int-1 risk MDS (IPSS) to study efficacy and safety of lenalidomide without (arm A) or with (arm B) ESA/G-CSF. In arm B, patients without erythroid response (HI-E) after 4 cycles received ESA; G-CSF was added if no HI-E was obtained by cycle 9. HI-E served as primary endpoint. Flow cytometry and next-generation sequencing were performed to identify predictors of response. The final evaluation comprised 184 patients; 84% non-del(5q), 16% isolated del(5q); median follow-up: 70.7 months. In arm A and B, 39 and 41% of patients achieved HI-E; median time-to-HI-E: 3.2 months for both arms, median duration of-HI-E: 9.8 months. HI-E was significantly lower in non-del(5q) vs. del(5q): 32% vs. 80%. The same accounted for transfusion independency-at-week 24 (16% vs. 67%), but similar in both arms. Apart from presence of del(5q), high percentages of bone marrow lymphocytes and progenitor B-cells, a low number of mutations, absence of ring sideroblasts, and SF3B1 mutations predicted HI-E. In conclusion, lenalidomide induced HI-E in patients with non-del(5q) and del(5q) MDS without additional effect of ESA/G-CSF. The identified predictors of response may guide application of lenalidomide in lower-risk MDS in the era of precision medicine. (EudraCT 2008-002195-10).
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Affiliation(s)
- A A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - E M P Cremers
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine - Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Alhan
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - C Duetz
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F E M In 't Hout
- Department of Laboratory Medicine - Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - D A Chitu
- HOVON Foundation, Rotterdam, The Netherlands
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A Verbrugge
- HOVON Foundation, Rotterdam, The Netherlands
| | - S M Cunha
- HOVON Foundation, Rotterdam, The Netherlands
| | - G J Ossenkoppele
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J J W M Janssen
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S K Klein
- Department of Hematology, Meander Medisch Centrum, Amersfoort, The Netherlands
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E Vellenga
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - G A Huls
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - P Muus
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Haematology, St. James University Hospital, Leeds, UK
| | - S M C Langemeijer
- Department of Laboratory Medicine - Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G E de Greef
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - P A W Te Boekhorst
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M H G Raaijmakers
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - M C Legdeur
- Department of Hematology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J J Wegman
- Department of Hematology, Deventer Ziekenhuis, Deventer, The Netherlands
- Department of Hematology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - W Deenik
- Department of Internal Medicine, Tergooi Ziekenhuis, Hilversum, The Netherlands
- Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands
| | - O de Weerdt
- Department of Internal Medicine, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | - P Jobse
- Department of Internal Medicine, Admiraal de Ruyter Ziekenhuis, Goes, The Netherlands
| | - R J W van Kampen
- Department of Internal Medicine, Zuyderland Ziekenhuis, Geleen, The Netherlands
| | - A Beeker
- Department of Hematology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - P W Wijermans
- Department of Hematology, Haaglanden Ziekenhuis, Den Haag, The Netherlands
| | - B J Biemond
- Department of Hematology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - B C Tanis
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, The Netherlands
- Department of General Practice Erasmus MC, Rotterdam, The Netherlands
| | - J W J van Esser
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | - C G Schaar
- Department of Internal Medicine, Gelre Ziekenhuis, Apeldoorn, The Netherlands
| | - H S Noordzij-Nooteboom
- Department of Internal Medicine, Van Weel Bethesda Ziekenhuis, Dirksland, The Netherlands
| | - E M G Jacobs
- Department of Internal Medicine, Elkerliek Ziekenhuis, Helmond, The Netherlands
| | - A O de Graaf
- Department of Laboratory Medicine - Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Jongen-Lavrencic
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M J P L Stevens-Kroef
- Department of human genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T M Westers
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J H Jansen
- Department of Laboratory Medicine - Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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van der Maas NG, Versluis J, Nasserinejad K, van Rosmalen J, Pabst T, Maertens J, Breems D, Manz M, Cloos J, Ossenkoppele GJ, Floisand Y, Gradowska P, Löwenberg B, Huls G, Postmus D, Pignatti F, Cornelissen JJ. Bayesian interim analysis for prospective randomized studies: reanalysis of the acute myeloid leukemia HOVON 132 clinical trial. Blood Cancer J 2024; 14:56. [PMID: 38538587 PMCID: PMC10973506 DOI: 10.1038/s41408-024-01037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/07/2024] Open
Abstract
Randomized controlled trials (RCTs) are the gold standard to establish the benefit-risk ratio of novel drugs. However, the evaluation of mature results often takes many years. We hypothesized that the addition of Bayesian inference methods at interim analysis time points might accelerate and enforce the knowledge that such trials may generate. In order to test that hypothesis, we retrospectively applied a Bayesian approach to the HOVON 132 trial, in which 800 newly diagnosed AML patients aged 18 to 65 years were randomly assigned to a "7 + 3" induction with or without lenalidomide. Five years after the first patient was recruited, the trial was negative for its primary endpoint with no difference in event-free survival (EFS) between experimental and control groups (hazard ratio [HR] 0.99, p = 0.96) in the final conventional analysis. We retrospectively simulated interim analyses after the inclusion of 150, 300, 450, and 600 patients using a Bayesian methodology to detect early lack of efficacy signals. The HR for EFS comparing the lenalidomide arm with the control treatment arm was 1.21 (95% CI 0.81-1.69), 1.05 (95% CI 0.86-1.30), 1.00 (95% CI 0.84-1.19), and 1.02 (95% CI 0.87-1.19) at interim analysis 1, 2, 3 and 4, respectively. Complete remission rates were lower in the lenalidomide arm, and early deaths more frequent. A Bayesian approach identified that the probability of a clinically relevant benefit for EFS (HR < 0.76, as assumed in the statistical analysis plan) was very low at the first interim analysis (1.2%, 0.6%, 0.4%, and 0.1%, respectively). Similar observations were made for low probabilities of any benefit regarding CR. Therefore, Bayesian analysis significantly adds to conventional methods applied for interim analysis and may thereby accelerate the performance and completion of phase III trials.
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Affiliation(s)
- Niek G van der Maas
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Thomas Pabst
- University Hospital, Inselspital, Bern, Switzerland
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | | | | | - Markus Manz
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
- University Hospital Zurich, Zurich, Switzerland
| | - Jacqueline Cloos
- Amsterdam UMC, location VUMC, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gert J Ossenkoppele
- Amsterdam UMC, location VUMC, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Patrycja Gradowska
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
- HOVON Foundation, Rotterdam, the Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gerwin Huls
- University Medical Center, University Groningen, Groningen, the Netherlands
| | - Douwe Postmus
- Oncology and Hematology Office, European Medicines Agency, Amsterdam, the Netherlands
| | - Francesco Pignatti
- Oncology and Hematology Office, European Medicines Agency, Amsterdam, the Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus Medical Center Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
- Oncology and Hematology Office, European Medicines Agency, Amsterdam, the Netherlands.
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3
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Tettero JM, Heidinga ME, Mocking TR, Fransen G, Kelder A, Scholten WJ, Snel AN, Ngai LL, Bachas C, van de Loosdrecht AA, Ossenkoppele GJ, de Leeuw DC, Cloos J, Janssen JJWM. Impact of hemodilution on flow cytometry based measurable residual disease assessment in acute myeloid leukemia. Leukemia 2024; 38:630-639. [PMID: 38272991 PMCID: PMC10912027 DOI: 10.1038/s41375-024-02158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/27/2024]
Abstract
Measurable residual disease (MRD) measured in the bone marrow (BM) of acute myeloid leukemia (AML) patients after induction chemotherapy is an established prognostic factor. Hemodilution, stemming from peripheral blood (PB) mixing within BM during aspiration, can yield false-negative MRD results. We prospectively examined hemodilution by measuring MRD in BM aspirates obtained from three consecutive 2 mL pulls, along with PB samples. Our results demonstrated a significant decrease in MRD percentages between the first and second pulls (P = 0.025) and between the second and third pulls (P = 0.025), highlighting the impact of hemodilution. Initially, 39% of MRD levels (18/46 leukemia-associated immunophenotypes) exceeded the 0.1% cut-off, decreasing to 30% (14/46) in the third pull. Additionally, we assessed the performance of six published methods and parameters for distinguishing BM from PB samples, addressing or compensating for hemodilution. The most promising results relied on the percentages of CD16dim granulocytic population (scarce in BM) and CD117high mast cells (exclusive to BM). Our findings highlight the importance of estimating hemodilution in MRD assessment to qualify MRD results, particularly near the common 0.1% cut-off. To avoid false-negative results by hemodilution, it is essential to collect high-quality BM aspirations and preferably utilizing the initial pull for MRD testing.
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Affiliation(s)
- Jesse M Tettero
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Maaike E Heidinga
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Tim R Mocking
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Glenn Fransen
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Angèle Kelder
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Willemijn J Scholten
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Alexander N Snel
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Lok Lam Ngai
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Costa Bachas
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Arjan A van de Loosdrecht
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - David C de Leeuw
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Jacqueline Cloos
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Hematology, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
| | - Jeroen J W M Janssen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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4
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Tettero JM, Buisman Y, Ngai LL, Bachas C, Gjertsen BT, Kelder A, van de Loosdrecht AA, Manz MG, Pabst T, Scholten W, Ossenkoppele GJ, Cloos J, de Leeuw DC. Prognostic Significance of Measurable Residual Disease Detection by Flow Cytometry in Autologous Stem Cell Apheresis Products in AML. Hemasphere 2023; 7:e981. [PMID: 38026789 PMCID: PMC10664848 DOI: 10.1097/hs9.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Jesse M. Tettero
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Yara Buisman
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Lok Lam Ngai
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Costa Bachas
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | | | - Angèle Kelder
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Arjan A. van de Loosdrecht
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Markus G. Manz
- Department of Medical Oncology and Hematology, University Hospital, Zurich, Switzerland
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - Thomas Pabst
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
- Department of Medical Oncology, Inselspital, University Hospital, Bern, Switzerland
| | - Willemijn Scholten
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - David C. de Leeuw
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
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5
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Tettero JM, Ngai LL, Bachas C, Breems DA, Fischer T, Gjertsen BT, Gradowska P, Griskevicius L, Janssen JJWM, Juliusson G, Maertens J, Manz MG, Pabst T, Passweg J, Porkka K, Valk PJM, Löwenberg B, Ossenkoppele GJ, Cloos J. Measurable residual disease-guided therapy in intermediate-risk acute myeloid leukemia patients is a valuable strategy in reducing allogeneic transplantation without negatively affecting survival. Haematologica 2023; 108:2794-2798. [PMID: 37021540 PMCID: PMC10542837 DOI: 10.3324/haematol.2022.282639] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Affiliation(s)
- Jesse M Tettero
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Lok Lam Ngai
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Costa Bachas
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | | | - Thomas Fischer
- Otto von Guericke University Hospital Magdeburg, Magdeburg, Germany
| | | | - Patrycja Gradowska
- Dutch-Belgian Hemato-Oncology Cooperative Group Data Center-Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Laimonas Griskevicius
- Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Jeroen J W M Janssen
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | | | | | - Markus G Manz
- University Hospital, Zurich, Switzerland; Swiss Group for Clinical Cancer Research(SAKK), Bern, Switzerland
| | - Thomas Pabst
- Swiss Group for Clinical Cancer Research(SAKK), Bern, Switzerland; Department of Medical Oncology, Inselspital; University Hospital, Bern, Switzerland
| | - Jakob Passweg
- Swiss Group for Clinical Cancer Research(SAKK), Bern, Switzerland; University Hospital, Basel, Switzerland
| | - Kimmo Porkka
- Helsinki University Hospital Cancer Center, Helsinki, Finland
| | - Peter J M Valk
- Erasmus University Medical Center (MC) and Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bob Löwenberg
- Erasmus University Medical Center (MC) and Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Gert J Ossenkoppele
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jacqueline Cloos
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands.
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6
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Jansen G, Al M, Assaraf YG, Kammerer S, van Meerloo J, Ossenkoppele GJ, Cloos J, Peters GJ. Statins markedly potentiate aminopeptidase inhibitor activity against (drug-resistant) human acute myeloid leukemia cells. Cancer Drug Resist 2023; 6:430-446. [PMID: 37842233 PMCID: PMC10571057 DOI: 10.20517/cdr.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/22/2023] [Accepted: 06/25/2023] [Indexed: 09/15/2023]
Abstract
Aim: This study aimed to decipher the molecular mechanism underlying the synergistic effect of inhibitors of the mevalonate-cholesterol pathway (i.e., statins) and aminopeptidase inhibitors (APis) on APi-sensitive and -resistant acute myeloid leukemia (AML) cells. Methods: U937 cells and their sublines with low and high levels of acquired resistance to (6S)-[(R)-2-((S)-Hydroxy-hydroxycarbamoyl-methoxy-methyl)-4-methyl-pentanoylamino]-3,3 dimethyl-butyric acid cyclopentyl ester (CHR2863), an APi prodrug, served as main AML cell line models. Drug combination effects were assessed with CHR2863 and in vitro non-toxic concentrations of various statins upon cell growth inhibition, cell cycle effects, and apoptosis induction. Mechanistic studies involved analysis of Rheb prenylation required for mTOR activation. Results: A strong synergy of CHR2863 with the statins simvastatin, fluvastatin, lovastatin, and pravastatin was demonstrated in U937 cells and two CHR2863-resistant sublines. This potent synergy between simvastatin and CHR2863 was also observed with a series of other human AML cell lines (e.g., THP1, MV4-11, and KG1), but not with acute lymphocytic leukemia or multiple solid tumor cell lines. This synergistic activity was: (i) specific for APis (e.g., CHR2863 and Bestatin), rather than for other cytotoxic agents; and (ii) corroborated by enhanced induction of apoptosis and cell cycle arrest which increased the sub-G1 fraction. Consistently, statin potentiation of CHR2863 activity was abrogated by co-administration of mevalonate and/or farnesyl pyrophosphate, suggesting the involvement of protein prenylation; this was experimentally confirmed by impaired Rheb prenylation by simvastatin. Conclusion: These novel findings suggest that the combined inhibitory effect of impaired Rheb prenylation and CHR2863-dependent mTOR inhibition instigates a potent synergistic inhibition of statins and APis on human AML cells.
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Affiliation(s)
- Gerrit Jansen
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
| | - Marjon Al
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
| | - Yehuda G. Assaraf
- The Fred Wyszkowsky Cancer Research Laboratory, Faculty of Biology, The Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Sarah Kammerer
- Department of Medical Oncology, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
- Institute of Biotechnology, Molecular Cell Biology, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg 01968, Germany
| | - Johan van Meerloo
- Department of Hematology, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
| | - Godefridus J. Peters
- Department of Medical Oncology, Amsterdam University Medical Center, location VUmc, Amsterdam 1081 HV, The Netherlands
- Department of Biochemistry, Medical University of Gdansk, Gdansk 80-210, Poland
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7
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Hilberink JR, van Zeventer IA, Chitu DA, Pabst T, Klein SK, Stussi G, Griskevicius L, Valk PJM, Cloos J, van de Loosdrecht AA, Breems D, van Lammeren-Venema D, Boersma R, Jongen-Lavrencic M, Fehr M, Hoogendoorn M, Manz MG, Söhne M, van Marwijk Kooy R, Deeren D, van der Poel MWM, Legdeur MC, Tick L, Chalandon Y, Ammatuna E, Blum S, Löwenberg B, Ossenkoppele GJ, Huls G. Age and sex associate with outcome in older AML and high risk MDS patients treated with 10-day decitabine. Blood Cancer J 2023; 13:93. [PMID: 37336890 DOI: 10.1038/s41408-023-00850-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/10/2023] [Accepted: 05/02/2023] [Indexed: 06/21/2023] Open
Abstract
Treatment choice according to the individual conditions remains challenging, particularly in older patients with acute myeloid leukemia (AML) and high risk myelodysplastic syndrome (MDS). The impact of performance status, comorbidities, and physical functioning on survival is not well defined for patients treated with hypomethylating agents. Here we describe the impact of performance status (14% ECOG performance status 2), comorbidity (40% HCT-comorbidity index ≥ 2), and physical functioning (41% short physical performance battery < 9 and 17% ADL index < 6) on overall survival (OS) in 115 older patients (age ≥ 66 years) treated on a clinical trial with a 10-day decitabine schedule. None of the patient-related variables showed a significant association with OS. Multivariable analysis revealed that age > 76 years was significantly associated with reduced OS (HR 1.58; p = 0.043) and female sex was associated with superior OS (HR 0.62; p = 0.06). We further compared the genetic profiles of these subgroups. This revealed comparable mutational profiles in patients younger and older than 76 years, but, interestingly, revealed significantly more prevalent mutated ASXL1, STAG2, and U2AF1 in male compared to female patients. In this cohort of older patients treated with decitabine age and sex, but not comorbidities, physical functioning or cytogenetic risk were associated with overall survival.
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Affiliation(s)
- Jacobien R Hilberink
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Dana A Chitu
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Thomas Pabst
- Department of Oncology, University Hospital, Inselspital, and University of Bern, Bern, Switzerland
| | - Saskia K Klein
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
- Department of Internal Medicine, Meander Hospital Amersfoort, Amersfoort, the Netherlands
| | - Georg Stussi
- Department of Hematology, Oncology Institute of Southern Switzerland, Ospedale Regionale, Bellinzona, Switzerland
| | - Laimonas Griskevicius
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center and Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Dimitri Breems
- Department of Hematology, ZNA Stuivenberg/Middelheim, Antwerp, Belgium
| | | | - Rinske Boersma
- Department of Hematology, Amphia Hospital, Breda, the Netherlands
| | - Mojca Jongen-Lavrencic
- Department of Hematology, Erasmus University Medical Center and Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Martin Fehr
- Department of Medical oncology and Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Mels Hoogendoorn
- Department of Hematology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Markus G Manz
- Department of Medical Oncology and Hematology, Universitätsspital Zurich, Zurich, Switzerland
| | - Maaike Söhne
- Department of Hematology, Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Dries Deeren
- Department of Hematology, AZ Delta Roeselare, Roeselare, Belgium
| | - Marjolein W M van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Lidwine Tick
- Department of hematology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Yves Chalandon
- Division of hematology, University Hospital Genève and Faculty of Medicine, University of Genève, Genève, Switzerland
| | - Emanuele Ammatuna
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Sabine Blum
- Service and Central Laboratory of Hematology, Department of Oncology and Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center and Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gerwin Huls
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands.
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8
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Ngai LL, Hanekamp D, Janssen F, Carbaat-Ham J, Hofland MAMA, Fayed MMHE, Kelder A, Oudshoorn-van Marsbergen L, Scholten WJ, Snel AN, Bachas C, Tettero JM, Breems DA, Fischer T, Gjertsen BT, Griškevičius L, Juliusson G, van de Loosdrecht AA, Maertens JA, Manz MG, Pabst T, Passweg JR, Porkka K, Valk PJM, Gradowska P, Löwenberg B, de Leeuw DC, Janssen JJWM, Ossenkoppele GJ, Cloos J. Prospective validation of the prognostic relevance of CD34+CD38- AML stem cell frequency in the HOVON-SAKK132 trial. Blood 2023; 141:2657-2661. [PMID: 36898087 PMCID: PMC10646801 DOI: 10.1182/blood.2022019160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/03/2023] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Affiliation(s)
- Lok Lam Ngai
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Diana Hanekamp
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Hematology, Erasmus MC, Rotterdam, Netherlands
| | - Fleur Janssen
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Jannemieke Carbaat-Ham
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Maaike A. M. A. Hofland
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Mona M. H. E Fayed
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Angèle Kelder
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Laura Oudshoorn-van Marsbergen
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Willemijn J. Scholten
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Alexander N. Snel
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Costa Bachas
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Jesse M. Tettero
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Dimitri A. Breems
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Thomas Fischer
- Department of Hematology and Oncology, Otto von Guericke University Hospital Magdeburg, Magdeburg, Germany
| | - Bjørn T. Gjertsen
- Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - Laimonas Griškevičius
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Gunnar Juliusson
- Department of Hematology, Skanes University Hospital, Lund, Sweden
| | - Arjan A. van de Loosdrecht
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Johan A. Maertens
- Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Markus G. Manz
- Department of Medical Oncology and Hematology, University Hospital, Zurich, Switzerland
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Thomas Pabst
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
- Department of Medical Oncology, Inselspital, University Hospital, Bern, Switzerland
| | - Jakob R. Passweg
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
- Department of Hematology, University Hospital, Basel, Switzerland
| | - Kimmo Porkka
- Department of Hematology, Helsinki University Hospital Cancer Center, Helsinki, Finland
| | | | - Patrycja Gradowska
- Dutch-Belgian Hemato-Oncology Cooperative Group Data Center–Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus MC, Rotterdam, Netherlands
| | - David C. de Leeuw
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Jeroen J. W. M. Janssen
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Cancer Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
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9
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Grob T, Sanders MA, Vonk CM, Kavelaars FG, Rijken M, Hanekamp DW, Gradowska PL, Cloos J, Fløisand Y, van Marwijk Kooy M, Manz MG, Ossenkoppele GJ, Tick LW, Havelange V, Löwenberg B, Jongen-Lavrencic M, Valk PJ. Prognostic Value of FLT3-Internal Tandem Duplication Residual Disease in Acute Myeloid Leukemia. J Clin Oncol 2023; 41:756-765. [PMID: 36315929 PMCID: PMC9901965 DOI: 10.1200/jco.22.00715] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The applicability of FLT3-internal tandem duplications (FLT3-ITD) for assessing measurable residual disease (MRD) in acute myeloid leukemia (AML) in complete remission (CR) has been hampered by patient-specific duplications and potential instability of FLT3-ITD during relapse. Here, we comprehensively investigated the impact of next-generation sequencing (NGS)-based FLT3-ITD MRD detection on treatment outcome in a cohort of patients with newly diagnosed AML in relation to established prognostic factors at diagnosis and other MRD measurements, ie, mutant NPM1 and multiparameter flow cytometry. METHODS In 161 patients with de novo FLT3-ITD AML, NGS was performed at diagnosis and in CR after intensive remission induction treatment. FLT3-ITD MRD status was correlated with the cumulative incidence of relapse and overall survival (OS). RESULTS NGS-based FLT3-ITD MRD was present in 47 of 161 (29%) patients with AML. Presence of FLT3-ITD MRD was associated with increased risk of relapse (4-year cumulative incidence of relapse, 75% FLT3-ITD MRD v 33% no FLT3-ITD MRD; P < .001) and inferior OS (4-year OS, 31% FLT3-ITD MRD v 57% no FLT3-ITD MRD; P < .001). In multivariate analysis, detection of FLT3-ITD MRD in CR confers independent prognostic significance for relapse (hazard ratio, 3.55; P < .001) and OS (hazard ratio 2.51; P = .002). Strikingly, FLT3-ITD MRD exceeds the prognostic value of most generally accepted clinical and molecular prognostic factors, including the FLT3-ITD allelic ratio at diagnosis and MRD assessment by NGS-based mutant NPM1 detection or multiparameter flow cytometry. CONCLUSION NGS-based detection of FLT3-ITD MRD in CR identifies patients with AML with profound risk of relapse and death that outcompetes the significance of most established prognostic factors at diagnosis and during therapy, and furnishes support for FLT3-ITD as a clinically relevant biomarker for dynamic disease risk assessment in AML.
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Affiliation(s)
- Tim Grob
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathijs A. Sanders
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Christian M. Vonk
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Franҫois G. Kavelaars
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melissa Rijken
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Diana W. Hanekamp
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands,Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Patrycja L. Gradowska
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Yngvar Fløisand
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | | | - Markus G. Manz
- Department of Medical Oncology and Hematology, Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Gert J. Ossenkoppele
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Lidwine W. Tick
- Department of Hematology, Maxima Medisch Centrum, Eindhoven, the Netherlands
| | - Violaine Havelange
- Department of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Bob Löwenberg
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mojca Jongen-Lavrencic
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Peter J.M. Valk
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands,Peter J.M. Valk, PhD, Department of Hematology, Erasmus University Medical Center Rotterdam, Nc 806, Wytemaweg 80, 3015 CN Rotterdam Z-H, the Netherlands; e-mail:
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10
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Tettero JM, Al-Badri WKW, Ngai LL, Bachas C, Breems DA, van Elssen CHMJ, Fischer T, Gjertsen BT, van Gorkom GNY, Gradowska P, Greuter MJE, Griskevicius L, Juliusson G, Maertens J, Manz MG, Pabst T, Passweg J, Porkka K, Löwenberg B, Ossenkoppele GJ, Janssen JJWM, Cloos J. Concordance in measurable residual disease result after first and second induction cycle in acute myeloid leukemia: An outcome- and cost-analysis. Front Oncol 2022; 12:999822. [PMID: 36300090 PMCID: PMC9589259 DOI: 10.3389/fonc.2022.999822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Measurable residual disease (MRD) measured using multiparameter flow-cytometry (MFC) has proven to be an important prognostic biomarker in acute myeloid leukemia (AML). In addition, MRD is increasingly used to guide consolidation treatment towards a non-allogenic stem cell transplantation treatment for MRD-negative patients in the ELN-2017 intermediate risk group. Currently, measurement of MFC-MRD in bone marrow is used for clinical decision making after 2 cycles of induction chemotherapy. However, measurement after 1 cycle has also been shown to have prognostic value, so the optimal time point remains a question of debate. We assessed the independent prognostic value of MRD results at either time point and concordance between these for 273 AML patients treated within and according to the HOVON-SAKK 92, 102, 103 and 132 trials. Cumulative incidence of relapse, event free survival and overall survival were significantly better for MRD-negative (<0.1%) patients compared to MRD-positive patients after cycle 1 and cycle 2 (p ≤ 0.002, for all comparisons). A total of 196 patients (71.8%) were MRD-negative after cycle 1, of which the vast majority remained negative after cycle 2 (180 patients; 91.8%). In contrast, of the 77 MRD-positive patients after cycle 1, only 41 patients (53.2%) remained positive. A cost reduction of –€571,751 per 100 patients could be achieved by initiating the donor search based on the MRD-result after cycle 1. This equals to a 50.7% cost reduction compared to the current care strategy in which the donor search is initiated for all patients. These results show that MRD after cycle 1 has prognostic value and is highly concordant with MRD status after cycle 2. When MRD-MFC is used to guide consolidation treatment (allo vs non-allo) in intermediate risk patients, allogeneic donor search may be postponed or omitted after cycle 1. Since the majority of MRD-negative patients remain negative after cycle 2, this could safely reduce the number of allogeneic donor searches and reduce costs.
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Affiliation(s)
- Jesse M. Tettero
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
- *Correspondence: Jesse M. Tettero,
| | - Waleed K. W. Al-Badri
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lok Lam Ngai
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
| | - Costa Bachas
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
| | - Dimitri A. Breems
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Catharina H. M. J. van Elssen
- Department of Internal Medicine, Division of Hematology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Thomas Fischer
- Department of Hematology and Oncology, Otto von Guericke University Hospital Magdeburg, Magdeburg, Germany
| | - Bjorn T. Gjertsen
- Department of Medicine, Hematology Section, Haukeland University Hospital, Bergen, Norway
| | - Gwendolyn N. Y. van Gorkom
- Department of Internal Medicine, Division of Hematology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Patrycja Gradowska
- The Dutch-Belgian Hemato-Oncology Cooperative Group (HOVON) Data Center, Department of Hematology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, Netherlands
| | - Marjolein J. E. Greuter
- Department of Epidemiology and Data Science, Amsterdam Univerisity Medical Centers, location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Laimonas Griskevicius
- Hematology, Oncology, Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Gunnar Juliusson
- Department of Hematology, Skanes University Hospital, Lund, Sweden
| | - Johan Maertens
- Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Markus G. Manz
- Department of Medical Oncology and Hematology, University Hospital, Zurich, Switzerland
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - Thomas Pabst
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
- Department of Medical Oncology, Inselspital, University Hospital, Bern, Switzerland
| | - Jakob Passweg
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
- Department of Hematology, University Hospital, Basel, Switzerland
| | - Kimmo Porkka
- Department of Hematology, Helsinki University Hospital Cancer Center, Helsinki, Finland
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center (MC) and Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
| | - Jeroen J. W. M. Janssen
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam Univerisity Medical Centers location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, Netherlands
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11
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van Gils N, Verhagen HJ, Broux M, Martiáñez T, Denkers F, Vermue E, Rutten A, Csikós T, Demeyer S, Çil M, Al M, Cools J, Janssen JJ, Ossenkoppele GJ, Menezes RX, Smit L. Targeting histone methylation to reprogram the transcriptional state that drives survival of drug-tolerant myeloid leukemia persisters. iScience 2022; 25:105013. [PMID: 36097617 PMCID: PMC9463578 DOI: 10.1016/j.isci.2022.105013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/20/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Although chemotherapy induces complete remission in the majority of acute myeloid leukemia (AML) patients, many face a relapse. This relapse is caused by survival of chemotherapy-resistant leukemia (stem) cells (measurable residual disease; MRD). Here, we demonstrate that the anthracycline doxorubicin epigenetically reprograms leukemia cells by inducing histone 3 lysine 27 (H3K27) and H3K4 tri-methylation. Within a doxorubicin-sensitive leukemia cell population, we identified a subpopulation of reversible anthracycline-tolerant cells (ATCs) with leukemic stem cell (LSC) features lacking doxorubicin-induced H3K27me3 or H3K4me3 upregulation. These ATCs have a distinct transcriptional landscape than the leukemia bulk and could be eradicated by KDM6 inhibition. In primary AML, reprogramming the transcriptional state by targeting KDM6 reduced MRD load and survival of LSCs residing within MRD, and enhanced chemotherapy response in vivo. Our results reveal plasticity of anthracycline resistance in AML cells and highlight the potential of transcriptional reprogramming by epigenetic-based therapeutics to target chemotherapy-resistant AML cells. Reversible anthracycline-tolerant leukemia cells (ATCs) have low H3K27me3 or H3K4me3 ATCs exhibit stem cell features similar to leukemic stem cells Reprogramming the transcriptional state by inhibition of KDM6 depletes ATCs Inhibiting KDM6 adds to doxorubicin treatment and eradicates AML MRD (stem) cells
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12
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Grob T, Al Hinai AS, Sanders MA, Kavelaars FG, Rijken M, Gradowska PL, Biemond BJ, Breems DA, Maertens J, van Marwijk Kooy M, Pabst T, de Weerdt O, Ossenkoppele GJ, van de Loosdrecht AA, Huls GA, Cornelissen JJ, Beverloo HB, Löwenberg B, Jongen-Lavrencic M, Valk PJ. Molecular characterization of mutant TP53 acute myeloid leukemia and high-risk myelodysplastic syndrome. Blood 2022; 139:2347-2354. [PMID: 35108372 PMCID: PMC11022827 DOI: 10.1182/blood.2021014472] [Citation(s) in RCA: 115] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
Substantial heterogeneity within mutant TP53 acute myeloid leukemia (AML) and myelodysplastic syndrome with excess of blast (MDS-EB) precludes the exact assessment of prognostic impact for individual patients. We performed in-depth clinical and molecular analysis of mutant TP53 AML and MDS-EB to dissect the molecular characteristics in detail and determine its impact on survival. We performed next-generation sequencing on 2200 AML/MDS-EB specimens and assessed the TP53 mutant allelic status (mono- or bi-allelic), the number of TP53 mutations, mutant TP53 clone size, concurrent mutations, cytogenetics, and mutant TP53 molecular minimal residual disease and studied the associations of these characteristics with overall survival. TP53 mutations were detected in 230 (10.5%) patients with AML/MDS-EB with a median variant allele frequency of 47%. Bi-allelic mutant TP53 status was observed in 174 (76%) patients. Multiple TP53 mutations were found in 49 (21%) patients. Concurrent mutations were detected in 113 (49%) patients. No significant difference in any of the aforementioned molecular characteristics of mutant TP53 was detected between AML and MDS-EB. Patients with mutant TP53 have a poor outcome (2-year overall survival, 12.8%); however, no survival difference between AML and MDS-EB was observed. Importantly, none of the molecular characteristics were significantly associated with survival in mutant TP53 AML/MDS-EB. In most patients, TP53 mutations remained detectable in complete remission by deep sequencing (73%). Detection of residual mutant TP53 was not associated with survival. Mutant TP53 AML and MDS-EB do not differ with respect to molecular characteristics and survival. Therefore, mutant TP53 AML/MDS-EB should be considered a distinct molecular disease entity.
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Affiliation(s)
- Tim Grob
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Adil S.A. Al Hinai
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- National Genetic Center, Royal Hospital, Ministry of Health, Muscat, Sultanate of Oman
| | - Mathijs A. Sanders
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - François G. Kavelaars
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Melissa Rijken
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrycja L. Gradowska
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J. Biemond
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dimitri A. Breems
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Johan Maertens
- Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - Thomas Pabst
- Department of Oncology, University Hospital, Inselspital, Bern, Switzerland
| | - Okke de Weerdt
- Department of Hematology, Saint Antonius Hospital, Nieuwegein, The Netherlands
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Gerwin A. Huls
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan J. Cornelissen
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H. Berna Beverloo
- Department of Clinical Genetics, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mojca Jongen-Lavrencic
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter J.M. Valk
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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13
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Santini V, Lübbert M, Wierzbowska A, Ossenkoppele GJ. Correction to: The Clinical Value of Decitabine Monotherapy in Patients with Acute Myeloid Leukemia. Adv Ther 2022; 39:1489. [PMID: 35169999 DOI: 10.1007/s12325-021-02033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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14
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Santini V, Lübbert M, Wierzbowska A, Ossenkoppele GJ. The Clinical Value of Decitabine Monotherapy in Patients with Acute Myeloid Leukemia. Adv Ther 2022; 39:1474-1488. [PMID: 34786648 PMCID: PMC8989816 DOI: 10.1007/s12325-021-01948-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
Decitabine (5-aza-2′-deoxycytidine) is a hypomethylating agent used in the treatment of acute myeloid leukemia (AML). Decitabine inhibits DNA methyltransferases, causing DNA hypomethylation, and leading amongst others to re-expression of silenced tumor suppressor genes. Decitabine is indicated for the treatment of adult patients with newly diagnosed de novo or secondary AML who are not eligible for standard induction chemotherapy. The initial authorization in 2012 was based on the results of the open-label, randomized, multicenter phase 3 DACO-016 trial, and supported by data from the supportive phase 2 open-label DACO-017 trial. Compared with standard care, decitabine significantly improved overall survival, event-free survival, progression-free survival, and response rate. Decitabine was generally well tolerated, offering a valuable treatment option in patients with AML irrespective of age, especially for patients achieving a complete response. Several observational “real-life” studies confirmed these results. In contrast to standard chemotherapy, the presence of adverse-risk karyotypes or TP53 mutations does not negatively impact sensitivity to hypomethylating therapy albeit with lower durability. Data suggest a potential positive effect of decitabine in patients with monosomal karyotype-positive AML. For the time being, decitabine is an appropriate option as monotherapy for patients with AML who are unfit to receive more intensive combination therapies, but emerging data suggest that decitabine-based doublet or triplet combinations may be future treatment options for patients with AML.
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Affiliation(s)
- Valeria Santini
- Department of Experimental and Clinical Medicine, MDS Unit, AOUC- University of Florence, Florence, Italy.
| | - Michael Lübbert
- Department of Internal Medicine I, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
| | | | - Gert J Ossenkoppele
- Department of Haematology, Location VU University Medical Center, Amsterdam, The Netherlands
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15
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Abstract
PURPOSE OF REVIEW Treatment of elderly patients with acute myeloid leukemia is a known challenge for hematologists due to patient diversity, heterogeneous disease biology, and a rapidly evolving treatment landscape. Here, we highlight the importance of determining fitness, review the latest therapeutic developments, and discuss clinical scenarios to provide guidance on individualized treatment for older AML patients. RECENT FINDINGS Several factors, like age, performance status, and comorbidities, play a role in fitness and are associated with outcome. Comorbidity scoring systems and geriatric assessments are tools to help physicians select the most appropriate treatment for each patient. The addition of venetoclax, targeted therapy with IDH1/2 and FLT3 inhibitors, and enhanced formulas of existing drugs like CPX-351 and oral azacitidine have improved responses and outcomes. New drugs and combination therapies have increased the therapeutic options for elderly AML patients but determination of fitness and disease biology is essential to select patient-tailored treatments.
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Affiliation(s)
- David C. de Leeuw
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Gert J. Ossenkoppele
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J. W. M. Janssen
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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16
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Heuser M, Freeman SD, Ossenkoppele GJ, Buccisano F, Hourigan CS, Ngai LL, Tettero JM, Bachas C, Baer C, Béné MC, Bücklein V, Czyz A, Denys B, Dillon R, Feuring-Buske M, Guzman ML, Haferlach T, Han L, Herzig JK, Jorgensen JL, Kern W, Konopleva MY, Lacombe F, Libura M, Majchrzak A, Maurillo L, Ofran Y, Philippe J, Plesa A, Preudhomme C, Ravandi F, Roumier C, Subklewe M, Thol F, van de Loosdrecht AA, van der Reijden BA, Venditti A, Wierzbowska A, Valk PJM, Wood BL, Walter RB, Thiede C, Döhner K, Roboz GJ, Cloos J. 2021 Update on MRD in acute myeloid leukemia: a consensus document from the European LeukemiaNet MRD Working Party. Blood 2021; 138:2753-2767. [PMID: 34724563 PMCID: PMC8718623 DOI: 10.1182/blood.2021013626] [Citation(s) in RCA: 270] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
Measurable residual disease (MRD) is an important biomarker in acute myeloid leukemia (AML) that is used for prognostic, predictive, monitoring, and efficacy-response assessments. The European LeukemiaNet (ELN) MRD Working Party evaluated standardization and harmonization of MRD in an ongoing manner and has updated the 2018 ELN MRD recommendations based on significant developments in the field. New and revised recommendations were established during in-person and online meetings, and a 2-stage Delphi poll was conducted to optimize consensus. All recommendations are graded by levels of evidence and agreement. Major changes include technical specifications for next-generation sequencing-based MRD testing and integrative assessments of MRD irrespective of technology. Other topics include use of MRD as a prognostic and surrogate end point for drug testing; selection of the technique, material, and appropriate time points for MRD assessment; and clinical implications of MRD assessment. In addition to technical recommendations for flow- and molecular-MRD analysis, we provide MRD thresholds and define MRD response, and detail how MRD results should be reported and combined if several techniques are used. MRD assessment in AML is complex and clinically relevant, and standardized approaches to application, interpretation, technical conduct, and reporting are of critical importance.
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Affiliation(s)
- Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancy, Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Lok Lam Ngai
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse M Tettero
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Costa Bachas
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Marie-Christine Béné
- Department of Hematology and Biology, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Veit Bücklein
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Anna Czyz
- Department of Hematology, Blood Neoplasms, and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Barbara Denys
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | | | - Monica L Guzman
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY
| | | | | | - Julia K Herzig
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | | | | | | | - Francis Lacombe
- Hematology Biology, Flow Cytometry, Bordeaux University Hospital, Pessac, France
| | | | - Agata Majchrzak
- Department of Experimental Hematology, Copernicus Memorial Hospital, Lodz, Poland
| | - Luca Maurillo
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Yishai Ofran
- Department of Hematology, Shaare Zedek Medical Center Faculty of Medicine Hebrew University, Jerusalem Israel
| | - Jan Philippe
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University
| | - Adriana Plesa
- Department of Hematology Laboratory, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | | | | | | | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Adriano Venditti
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | | | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Brent L Wood
- Department of Hematopathology, Children's Hospital Los Angeles, CA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Christian Thiede
- Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany; and
- AgenDix GmbH, Dresden, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Gail J Roboz
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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17
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Bakunina K, Putter H, Versluis J, Koster EAS, van der Holt B, Manz MG, Breems DA, Gjertsen BT, Cloos J, Valk PJM, Passweg J, Pabst T, Ossenkoppele GJ, Löwenberg B, Cornelissen JJ, de Wreede LC. The added value of multi-state modelling in a randomized controlled trial: The HOVON 102 study re-analyzed. Cancer Med 2021; 11:630-640. [PMID: 34953042 PMCID: PMC8817075 DOI: 10.1002/cam4.4392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/07/2022] Open
Abstract
Clofarabine is an active antileukemic drug for subgroups of patients with acute myeloid leukemia (AML). Multi-state models can provide additional insights to supplement the original intention-to-treat analysis of randomized controlled trials (RCT). We re-analyzed the HOVON102/SAKK30/09 phase III RCT for newly diagnosed AML patients, which randomized between standard induction chemotherapy with or without clofarabine. Using multi-state models, we evaluated the effects of induction chemotherapy outcomes (complete remission [CR], measurable residual disease [MRD]), and post-remission therapy with allogeneic stem cell transplantation [alloSCT] on relapse and death. Through the latter a consistent reduction in the hazard of relapse in the clofarabine arm compared to the standard arm was found, which occurred irrespective of MRD status or post-remission treatment with alloSCT, demonstrating a strong and persistent antileukemic effect of clofarabine. During the time period between achieving CR and possible post-remission treatment with alloSCT, non-relapse mortality was higher in patients receiving clofarabine. An overall net benefit of treatment with clofarabine was identified using the composite endpoint current leukemia-free survival (CLFS). In conclusion, these results enforce and extend the earlier reported beneficial effect of clofarabine in AML and show that multi-state models further detail the effect of treatment on competing and series of events.
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Affiliation(s)
- Katerina Bakunina
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Eva A S Koster
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Breems
- Department of Hematology, Hospital Network Antwerp Stuivenberg/Middelheim, Antwerp, Belgium
| | - Bjorn T Gjertsen
- Department of Internal Medicine, Hematology section, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jakob Passweg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, University Hospital/Inselspital, Bern, Switzerland
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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18
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Duetz C, Cucchi DGJ, Polak TB, Janssen JJWM, Ossenkoppele GJ, Estey EH, van de Loosdrecht AA. The wider perspective: twenty years of clinical trials in myelodysplastic syndromes. Br J Haematol 2021; 196:329-335. [PMID: 34632583 DOI: 10.1111/bjh.17892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 09/29/2021] [Indexed: 12/21/2022]
Abstract
Most patients with myelodysplastic syndromes (MDS) require therapeutic intervention. However, there are few approved treatments for MDS. To explore reasons, we searched clinicaltrials.gov and clinicaltrialsregister.eu for MDS trials from 2000 to 2020. We assessed which agents were under investigation and analysed clinical trial characteristics and continuation rates from phase I to II to III to approval. As such, we identified 384 unique agents in 426 phase I, 430 phase II and 48 phase III trials. Success rates for phase III trials and agents were low, and MDS trials took markedly longer to complete than the average clinical trial. Although success rates were higher when MDS-specific phase I trials were conducted, 52% of the agents had not been evaluated in a phase I trial for MDS. MDS trials often failed to include quality of life, an especially important outcome for older MDS patients. Our work identifies factors potentially contributing to the paucity of available agents for MDS. We suggest a framework to improve clinical research in MDS that might ultimately augment the number of available agents.
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Affiliation(s)
- Carolien Duetz
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - David G J Cucchi
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tobias B Polak
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Elihu H Estey
- Department of Hematology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location VUmc, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, The Netherlands
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19
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Ngai LL, Ma CY, Maguire O, Do AD, Robert A, Logan AC, Griffiths EA, Nemeth MJ, Green C, Pourmohamad T, van Kuijk BJ, Snel AN, Kwidama ZW, Venniker-Punt B, Cooper J, Manz MG, Gjertsen BT, Smit L, Ossenkoppele GJ, Janssen JJWM, Cloos J, Sumiyoshi T. Bimodal expression of potential drug target CLL-1 (CLEC12A) on CD34+ blasts of AML patients. Eur J Haematol 2021; 107:343-353. [PMID: 34053123 PMCID: PMC8457079 DOI: 10.1111/ejh.13672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/26/2021] [Indexed: 12/17/2022]
Abstract
Objectives This study aims to retrospectively assess C‐lectin‐like molecule 1 (CLL‐1) bimodal expression on CD34+ blasts in acute myeloid leukemia (AML) patients (total N = 306) and explore potential CLL‐1 bimodal associations with leukemia and patient‐specific characteristics. Methods Flow cytometry assays were performed to assess the deeper immunophenotyping of CLL‐1 bimodality. Cytogenetic analysis was performed to characterize the gene mutation on CLL‐1‐negative subpopulation of CLL‐1 bimodal AML samples. Results The frequency of a bimodal pattern of CLL‐1 expression of CD34+ blasts ranged from 8% to 65% in the different cohorts. Bimodal CLL‐1 expression was most prevalent in patients with MDS‐related AML (P = .011), ELN adverse risk (P = .002), NPM1 wild type (WT, P = .049), FLT3 WT (P = .035), and relatively low percentages of leukemia‐associated immunophenotypes (P = .006). Additional immunophenotyping analysis revealed the CLL‐1− subpopulation may consist of pre‐B cells, immature myeloblasts, and hematopoietic stem cells. Furthermore, (pre)‐leukemic mutations were detected in both CLL‐1+ and CLL‐1− subfractions of bimodal samples (N = 3). Conclusions C‐lectin‐like molecule 1 bimodality occurs in about 25% of AML patients and the CLL‐1− cell population still contains malignant cells, hence it may potentially limit the effectiveness of CLL‐1‐targeted therapies and warrant further investigation.
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Affiliation(s)
- Lok Lam Ngai
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Connie Y Ma
- Department of Development of Science, Genentech, South San Francisco, CA, USA
| | - Orla Maguire
- Flow and Image Cytometry Shared Resource, Buffalo, NY, USA
| | - An D Do
- Department of Development of Science, Genentech, South San Francisco, CA, USA
| | - Alberto Robert
- Department of Development of Science, Genentech, South San Francisco, CA, USA
| | - Aaron C Logan
- Department of Medicine, UCSF, San Francisco, CA, USA
| | | | | | - Cherie Green
- Department of Development of Science, Genentech, South San Francisco, CA, USA
| | | | - Bo J van Kuijk
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Alexander N Snel
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Zinia W Kwidama
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bianca Venniker-Punt
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - James Cooper
- Department of Early Clinical Development, Genentech, South San Francisco, CA, USA
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University and University Hospital, Zurich, Switzerland
| | - Bjørn T Gjertsen
- Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Linda Smit
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Teiko Sumiyoshi
- Department of Development of Science, Genentech, South San Francisco, CA, USA
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20
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Walter RB, Ofran Y, Wierzbowska A, Ravandi F, Hourigan CS, Ngai LL, Venditti A, Buccisano F, Ossenkoppele GJ, Roboz GJ. Measurable residual disease as a biomarker in acute myeloid leukemia: theoretical and practical considerations. Leukemia 2021; 35:1529-1538. [PMID: 33758317 DOI: 10.1038/s41375-021-01230-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/19/2021] [Accepted: 03/11/2021] [Indexed: 12/20/2022]
Abstract
Several methodologies that rely on the detection of immunophenotypic or molecular abnormalities of the neoplastic cells are now available to quantify measurable ("minimal") residual disease (MRD) in acute myeloid leukemia (AML). Although the perfect MRD test does not (yet) exist, the strong association between MRD and adverse patient outcomes has provided the impetus to use measures of MRD as biomarker in the routine care of AML patients and during clinical trials. MRD test results may inform the selection of postremission therapy in some patients but evidence supporting the use of MRD as predictive biomarker is still limited. Several retrospective studies have shown that conversion from undetectable to detectable MRD or increasing MRD over time is associated with overt disease recurrence, and MRD testing may therefore be valuable as a monitoring biomarker for early detection of relapse. Interpreting serial MRD data is complex, with open questions regarding the optimal timing and frequency of testing, as well as the identification of test-specific thresholds to define relapse. Importantly, it is unknown whether intervening at the time of MRD detection, rather than at overt disease recurrence, improves outcomes. Finally, using MRD as a surrogate efficacy-response biomarker to accelerate drug development/approval has already been accepted by regulatory authorities in other diseases and is of great interest as a potential strategy in AML. While the prognostic value of MRD in AML is well established, data from prospective clinical trials confirming that treatment effects on MRD directly relate to clinical outcomes are needed to further establish the role of MRD as a surrogate endpoint in AML.
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Affiliation(s)
- Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA. .,Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Yishai Ofran
- Department of Hematology, Sharee Zedeq Medical Center, Jerusalem, Israel
| | | | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lok Lam Ngai
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Adriano Venditti
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Gail J Roboz
- Hematology and Oncology, Weill Cornell Medicine and NewYork-Presbyterian Hospital, Cornell University, New York, NY, USA
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21
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Cucchi DGJ, Polak TB, Ossenkoppele GJ, Uyl-De Groot CA, Cloos J, Zweegman S, Janssen JJWM. Two decades of targeted therapies in acute myeloid leukemia. Leukemia 2021; 35:651-660. [PMID: 33589753 DOI: 10.1038/s41375-021-01164-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/11/2021] [Accepted: 01/26/2021] [Indexed: 12/23/2022]
Abstract
Precision medicine is gaining importance in the treatment of acute myeloid leukemia (AML). Objectively reviewing past and current knowledge aids guiding future research. Therefore, we provide a complete overview of all phase II and phase III trials investigating targeted therapies in AML and their primary endpoints over the past two decades in perspective of their clinical benefit. We assessed whether drugs were primarily designed to treat AML or were repurposed and how successful they were based on progression of distinct drugs from phase II to phase III to FDA-approval. Between January 2000 and September 2020, 167 agents with 96 targets were investigated in 397 phase II trials. Twenty-eight agents were steered towards phase III, after three phase II trials on average. Repurposed drugs less often advanced in clinical development than drugs primarily developed for AML. Composite responses were the most prevalent primary endpoints in phase II. Of the eight FDA-approved drugs, none investigated quality of life at time of approval, and three out of eight have yet to show benefit in overall survival. Returns on targeted therapy research remain lean for AML patients. Future trials should not overlook non-targeted agents and foremost study endpoints proven to predict patient well-being.
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Affiliation(s)
- David G J Cucchi
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Tobias B Polak
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Carin A Uyl-De Groot
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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22
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van Luijn MM, Chamuleau MED, Ossenkoppele GJ, van de Loosdrecht AA, Marieke van Ham S. Tumor immune escape in acute myeloid leukemia: Class II-associated invariant chain peptide expression as result of deficient antigen presentation. Oncoimmunology 2021; 1:211-213. [PMID: 22720245 PMCID: PMC3376995 DOI: 10.4161/onci.1.2.18100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In this overview, we discuss the role of class II-associated invariant chain peptide (CLIP) in acute myeloid leukemia (AML), one of the few tumors expressing HLA class II. The clinical impact, function and regulation of CLIP expression on leukemic cells is addressed, indicating its potential as immunotherapeutic target in AML.
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Affiliation(s)
- Marvin M van Luijn
- Department of Hematology; Cancer Center Amsterdam; VU Institute for Cancer and Immunology; VU University Medical Center; Amsterdam, The Netherlands ; Department of Immunopathology; Sanquin Research and Landsteiner Laboratory; Academic Medical Center; University of Amsterdam; Amsterdam, The Netherlands
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23
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Ngai LL, Kelder A, Janssen JJWM, Ossenkoppele GJ, Cloos J. MRD Tailored Therapy in AML: What We Have Learned So Far. Front Oncol 2021; 10:603636. [PMID: 33575214 PMCID: PMC7871983 DOI: 10.3389/fonc.2020.603636] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/16/2020] [Indexed: 12/22/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous clonal disease associated with a dismal survival, partly due to the frequent occurrence of relapse. Many patient- and leukemia-specific characteristics, such as age, cytogenetics, mutations, and measurable residual disease (MRD) after intensive chemotherapy, have shown to be valuable prognostic factors. MRD has become a rich field of research where many advances have been made regarding technical, biological, and clinical aspects, which will be the topic of this review. Since many laboratories involved in AML diagnostics have experience in immunophenotyping, multiparameter flow cytometry (MFC) based MRD is currently the most commonly used method. Although molecular, quantitative PCR based techniques may be more sensitive, their disadvantage is that they can only be applied in a subset of patients harboring the genetic aberration. Next-generation sequencing can assess and quantify mutations in many genes but currently does not offer highly sensitive MRD measurements on a routine basis. In order to provide reliable MRD results, MRD assay optimization and standardization is essential. Different techniques for MRD assessment are being evaluated, and combinations of the methods have shown promising results for improving its prognostic value. In this regard, the load of leukemic stem cells (LSC) has also been shown to add to the prognostic value of MFC-MRD. At this moment, MRD after intensive chemotherapy is most often used as a prognostic factor to help stratify patients, but also to select the most appropriate consolidation therapy. For example, to guide post-remission treatment for intermediate-risk patients where MRD positive patients receive allogeneic stem cell transplantation and MRD negative receive autologous stem cell transplantation. Other upcoming uses of MRD that are being investigated include: selecting the type of allogeneic stem cell transplantation therapy (donor, conditioning), monitoring after stem cell transplantation (to allow intervention), and determining drug efficacy for the use of a surrogate endpoint in clinical trials.
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Affiliation(s)
| | | | | | | | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, Netherlands
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24
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Wei AH, Döhner H, Pocock C, Montesinos P, Afanasyev B, Dombret H, Ravandi F, Sayar H, Jang JH, Porkka K, Selleslag D, Sandhu I, Turgut M, Giai V, Ofran Y, Kizil Çakar M, Botelho de Sousa A, Rybka J, Frairia C, Borin L, Beltrami G, Čermák J, Ossenkoppele GJ, La Torre I, Skikne B, Kumar K, Dong Q, Beach CL, Roboz GJ. Oral Azacitidine Maintenance Therapy for Acute Myeloid Leukemia in First Remission. N Engl J Med 2020; 383:2526-2537. [PMID: 33369355 DOI: 10.1056/nejmoa2004444] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although induction chemotherapy results in remission in many older patients with acute myeloid leukemia (AML), relapse is common and overall survival is poor. METHODS We conducted a phase 3, randomized, double-blind, placebo-controlled trial of the oral formulation of azacitidine (CC-486, a hypomethylating agent that is not bioequivalent to injectable azacitidine), as maintenance therapy in patients with AML who were in first remission after intensive chemotherapy. Patients who were 55 years of age or older, were in complete remission with or without complete blood count recovery, and were not candidates for hematopoietic stem-cell transplantation were randomly assigned to receive CC-486 (300 mg) or placebo once daily for 14 days per 28-day cycle. The primary end point was overall survival. Secondary end points included relapse-free survival and health-related quality of life. RESULTS A total of 472 patients underwent randomization; 238 were assigned to the CC-486 group and 234 were assigned to the placebo group. The median age was 68 years (range, 55 to 86). Median overall survival from the time of randomization was significantly longer with CC-486 than with placebo (24.7 months and 14.8 months, respectively; P<0.001). Median relapse-free survival was also significantly longer with CC-486 than with placebo (10.2 months and 4.8 months, respectively; P<0.001). Benefits of CC-486 with respect to overall and relapse-free survival were shown in most subgroups defined according to baseline characteristics. The most common adverse events in both groups were grade 1 or 2 gastrointestinal events. Common grade 3 or 4 adverse events were neutropenia (in 41% of patients in the CC-486 group and 24% of patients in the placebo group) and thrombocytopenia (in 22% and 21%, respectively). Overall health-related quality of life was preserved during CC-486 treatment. CONCLUSIONS CC-486 maintenance therapy was associated with significantly longer overall and relapse-free survival than placebo among older patients with AML who were in remission after chemotherapy. Side effects were mainly gastrointestinal symptoms and neutropenia. Quality-of-life measures were maintained throughout treatment. (Supported by Celgene; QUAZAR AML-001 ClinicalTrials.gov number, NCT01757535.).
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Affiliation(s)
- Andrew H Wei
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Hartmut Döhner
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Christopher Pocock
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Pau Montesinos
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Boris Afanasyev
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Hervé Dombret
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Farhad Ravandi
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Hamid Sayar
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Jun-Ho Jang
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Kimmo Porkka
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Dominik Selleslag
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Irwindeep Sandhu
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Mehmet Turgut
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Valentina Giai
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Yishai Ofran
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Merih Kizil Çakar
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Aida Botelho de Sousa
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Justyna Rybka
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Chiara Frairia
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Lorenza Borin
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Germana Beltrami
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Jaroslav Čermák
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Gert J Ossenkoppele
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Ignazia La Torre
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Barry Skikne
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Keshava Kumar
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Qian Dong
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - C L Beach
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
| | - Gail J Roboz
- From the Department of Clinical Haematology, Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia (A.H.W.); the Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany (H. Döhner); Kent and Canterbury Hospital, Canterbury, United Kingdom (C.P.); Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, and Hospital Universitari i Politècnic La Fe, Valencia - both in Spain (P.M.); Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia (B.A.); the Department of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Institut de Recherche Saint-Louis, Université de Paris, Paris (H. Dombret); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (F.R.); Indiana University Cancer Center, Indianapolis (H.S.); Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.H.J.); Hospital District of Helsinki and Uusimaa (HUS) Comprehensive Cancer Center, Hematology Research Unit Helsinki and iCAN Digital Precision Cancer Center Medicine Flagship, University of Helsinki, Helsinki (K.P.); AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium (D.S.); University of Alberta Hospital, Edmonton, Canada (I.S.); Ondokuz Mayis University, Samsun (M.T.), and Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara (M.K.C.) - both in Turkey; Antonio e Biagio e Cesare Arrigo Hospital, Alessandria (V.G.), Città della Salute e della Scienza, Turin (C.F.), Ospedale San Gerardo Monza, Monza (L.B.), and Ospedale Policlinico San Martino, Genoa (G.B.) - all in Italy; Rambam Medical Center and Faculty of Medicine Technion, Haifa, Israel (Y.O.); Hospital dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal (A.B.S.); Wroclaw Medical University, Wroclaw, Poland (J.R.); Ústav Hematologie a Krevní Transfuze, Prague, Czech Republic (J.C.); Amsterdam University Medical Center, Location VUMC (Vrije Universiteit Medical Center), Amsterdam (G.J.O.); Celgene (Bristol Myers Squibb), Boudry, Switzerland (I.L.T.); Bristol Myers Squibb, Princeton, NJ (B.S., K.K., Q.D., C.L.B.); University of Kansas Medical Center, Kansas City (B.S.); and Weill Cornell Medicine and New York Presbyterian Hospital, New York (G.J.R.)
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25
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van Gils N, Verhagen HJ, Martiáñez T, Denkers F, Vermue E, Rutten A, Csikós T, Çil M, Al M, van Gemert F, Janssen JJ, Ossenkoppele GJ, Menezes RX, Smit L. Abstract PO-125: Targeting histone methylation to overrule transcriptionally driven drug resistance in myeloid leukemia. Cancer Res 2020. [DOI: 10.1158/1538-7445.tumhet2020-po-125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Standard induction chemotherapy, consisting of an anthracycline and cytarabine, has been the first-line therapeutic to treat acute myeloid leukemia (AML). Although this treatment induces complete remissions (CR) in the majority of patients, many face a relapse. Relapse is caused by the survival of chemotherapy-resistant leukemia cells (minimal residual disease, MRD), that may have acquired drug resistance by non-genetic mechanisms. Persistence of MRD is driven by intra-leukemic heterogeneity and plasticity in response to therapy. Leukemia cells within MRD capable of initiating relapse are thought to have stem cell features and are therefore named “leukemic stem cells” (LSCs). In this study, we demonstrated that the anthracycline doxorubicin epigenetically reprograms leukemia cells by inducing tri-methylation of histone 3 lysine 27 (H3K27) and H3K4. Moreover, to understand chemotherapy resistance at the single-cell level and to study intra-leukemia heterogeneity with respect to anthracycline sensitivity, we seeded K562 myeloid leukemia cells in 480 wells, each containing 10.000 cells, and treated the cells with increasing concentrations of doxorubicin. Using this approach, a subpopulation of reversible anthracycline-tolerant cells (ATCs) was identified within the doxorubicin-sensitive leukemia cell population, which lacked upregulation of H3K27me3 or H3K4me3 and exhibited epigenetically regulated expression of stem cell features similar to leukemic stem cells (LSCs). These ATCs have a distinct transcriptional landscape from the leukemia bulk and could be eradicated by the KDM6 inhibitor GSK-J4. In primary human AML, GSK-J4 treatment could eliminate AML blasts and LSCs at diagnosis but importantly it could significantly reduce chemotherapy resistant AML patient cell load (MRD) and survival of LSCs residing within MRD, ex vivo and in vivo. An efficient response to GSK-J4 was associated with upregulation of H3K27 and/or H3K4 methylation, and downregulation of STAT5B. Together, our results reveal plasticity of anthracycline resistance in AML cells and highlight the potential of epigenetic-based therapeutics to target chemotherapy-resistant AML cells.
Citation Format: Noortje van Gils, Han J.M.P. Verhagen, Tània Martiáñez, Fedor Denkers, Eline Vermue, Arjo Rutten, Tamás Csikós, Meyrem Çil, Marjon Al, Frank van Gemert, Jeroen J.W.M. Janssen, Gert J. Ossenkoppele, Renee X. Menezes, Linda Smit. Targeting histone methylation to overrule transcriptionally driven drug resistance in myeloid leukemia [abstract]. In: Proceedings of the AACR Virtual Special Conference on Tumor Heterogeneity: From Single Cells to Clinical Impact; 2020 Sep 17-18. Philadelphia (PA): AACR; Cancer Res 2020;80(21 Suppl):Abstract nr PO-125.
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Affiliation(s)
| | | | | | - Fedor Denkers
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | - Eline Vermue
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | - Arjo Rutten
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | - Tamás Csikós
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | - Meyrem Çil
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | - Marjon Al
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
| | | | | | | | | | - Linda Smit
- Amsterdam UMC, locatie VUmc, Amsterdam, The Netherlands
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26
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Kalin B, van Norden Y, van Gelder M, Breems D, Maertens J, Jongen-Lavrencic M, Broers AEC, Braakman E, Grob T, Zeijlemaker W, Ossenkoppele GJ, Meijer E, Cornelissen JJ. Panobinostat and decitabine prior to donor lymphocyte infusion in allogeneic stem cell transplantation. Blood Adv 2020; 4:4430-4437. [PMID: 32936907 PMCID: PMC7509859 DOI: 10.1182/bloodadvances.2020002074] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022] Open
Abstract
Outcome after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is adversely affected by relapse to a considerable degree. To exploit the graft-versus-leukemia effect more effectively, we assessed the feasibility of early initiation of epigenetic therapy with panobinostat and decitabine after allo-HSCT and before donor lymphocyte infusion (DLI) in poor-risk patients with acute myeloid leukemia (AML) or refractory anemia with excess blasts with International Prognostic Scoring System score ≥1.5. A total of 140 poor-risk patients with AML aged 18 to 70 years were registered, and 110 proceeded to allo-HSCT. Three dose levels were evaluated for dose-limiting toxicities, including panobinostat monotherapy 20 mg at days 1, 4, 8, and 11 of a 4-week cycle (PNB mono group) and panobinostat combined with either decitabine 20 mg/m2 (PNB/DAC20 group) or decitabine 10 mg/m2 (PNB/DAC10 group) at days 1 to 3 of every 4-week cycle. After phase 1, the study continued as phase 2, focusing on completion of protocol treatment and treatment outcome. PNB mono and PNB/DAC10 were feasible, whereas PNB/DAC20 was not related to prolonged cytopenia. Sixty of 110 patients who underwent transplantation were eligible to receive their first DLI within 115 days after allo-HSCT. Grade 3 and 4 adverse events related to panobinostat and decitabine were observed in 23 (26%) of the 87 patients, and they received epigenetic therapy. Cumulative incidence of relapse was 35% (standard error [SE] 5), and overall survival and progression-free survival at 24 months were 50% (SE 5) and 49% (SE 5). Post-allo-HSCT epigenetic therapy with panobinostat alone or in combination with low-dose decitabine is feasible and is associated with a relatively low relapse rate. The trial was registered at the European Clinical Trial Registry, https://www.clinicaltrialsregister.eu, as ECT2012-003344-74.
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Affiliation(s)
- Burak Kalin
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Yvette van Norden
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Michel van Gelder
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dimitri Breems
- Department of Hematology, Hospital Network Antwerp, Campus Stuivenberg, Antwerp, Belgium
| | - Johan Maertens
- Department of Hematology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium; and
| | - Mojca Jongen-Lavrencic
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Annoek E C Broers
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Eric Braakman
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Tim Grob
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Wendelien Zeijlemaker
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ellen Meijer
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
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27
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Huls G, Chitu DA, Pabst T, Klein SK, Stussi G, Griskevicius L, Valk PJM, Cloos J, van de Loosdrecht AA, Breems D, van Lammeren-Venema D, van Zeventer I, Boersma R, Jongen-Lavrencic M, Fehr M, Hoogendoorn M, Manz MG, Söhne M, van Marwijk Kooy R, Deeren D, van der Poel MWM, Legdeur MC, Tick L, Chalandon Y, Ammatuna E, Blum S, Löwenberg B, Ossenkoppele GJ. Ibrutinib added to 10-day decitabine for older patients with AML and higher risk MDS. Blood Adv 2020; 4:4267-4277. [PMID: 32915972 PMCID: PMC7509861 DOI: 10.1182/bloodadvances.2020002846] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/17/2020] [Indexed: 12/30/2022] Open
Abstract
The treatment of older, unfit patients with acute myeloid leukemia (AML) is challenging. Based on preclinical data of Bruton tyrosine kinase expression/phosphorylation and ibrutinib cytotoxicity in AML blasts, we conducted a randomized phase 2 multicenter study to assess the tolerability and efficacy of the addition of ibrutinib to 10-day decitabine in unfit (ie, Hematopoietic Cell Transplantation Comorbidity Index ≥3) AML patients and higher risk myelodysplasia patients (HOVON135/SAKK30/15 trial). In total, 144 eligible patients were randomly (1:1) assigned to either 10-day decitabine combined with ibrutinib (560 mg; sequentially given, starting the day after the last dose of decitabine) (n = 72) or to 10-day decitabine (n = 72). The addition of ibrutinib was well tolerated, and the number of adverse events was comparable for both arms. In the decitabine plus ibrutinib arm, 41% reached complete remission/complete remission with incomplete hematologic recovery (CR/CRi), the median overall survival (OS) was 11 months, and 2-year OS was 27%; these findings compared with 50% CR/CRi, median OS of 11.5 months, and 2-year OS of 21% for the decitabine group (not significant). Extensive molecular profiling at diagnosis revealed that patients with STAG2, IDH2, and ASXL1 mutations had significantly lower CR/CRi rates, whereas patients with mutations in TP53 had significantly higher CR/CRi rates. Furthermore, multicolor flow cytometry revealed that after 3 cycles of treatment, 28 (49%) of 57 patients with available bone marrow samples had no measurable residual disease. In this limited number of cases, measurable residual disease revealed no apparent impact on event-free survival and OS. In conclusion, the addition of ibrutinib does not improve the therapeutic efficacy of decitabine. This trial was registered at the Netherlands Trial Register (NL5751 [NTR6017]) and has EudraCT number 2015-002855-85.
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Affiliation(s)
- Gerwin Huls
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dana A Chitu
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Thomas Pabst
- Department of Oncology, University Hospital, Inselspital, and University of Bern, Bern, Switzerland
| | - Saskia K Klein
- Department of Hematology, Meander Hospital Amersfoort, Amersfoort, The Netherlands
| | - Georg Stussi
- Department of Hematology, Ospedale Regionale, Bellinzona, Switzerland
| | - Laimonas Griskevicius
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Dimitri Breems
- Department of Hematology, ZNA Stuivenberg/Middelheim, Antwerp, Belgium
| | | | - Isabelle van Zeventer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Rinske Boersma
- Department of Hematology, Amphia Hospital, Breda, The Netherlands
| | | | - Martin Fehr
- Department of Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Mels Hoogendoorn
- Department of Hematology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Markus G Manz
- Department of Medical Oncology and Hematology, Universitätsspital Zurich, Zurich, Switzerland
| | - Maaike Söhne
- Department of Hematology, Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Dries Deeren
- Department of Hematology, AZ Delta Roeselare, Roeselare, Belgium
| | | | | | - Lidwine Tick
- Department of Hematology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Yves Chalandon
- Division of Hematology, University Hospital Genève and Faculty of Medicine, University of Genève, Genève, Switzerland; and
| | - Emanuele Ammatuna
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Sabine Blum
- Service and Central Laboratory of Hematology, Department of Oncology and Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Ravandi F, Wei A, Dohner H, Dombret H, Ossenkoppele GJ, Pfeilstöcker M, Thol F, Feldman G, Voso MT, Marlton P, Harvey M, Santini V, Fianchi L, Candoni A, La Torre I, Skikne B, Kumar K, Dong Q, Beach CL, Roboz GJ. CC-486 is safe and well-tolerated as maintenance therapy in elderly patients (≥75 years) with acute myeloid leukemia (AML) in first remission following induction chemotherapy: Results from the phase III QUAZAR AML-001 trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7530 Background: About 40-50% of older patients (pts) with AML attain complete remission (CR) with induction chemotherapy (IC) but relapse is common.Effective, well-tolerated maintenance treatment (Tx) is needed for older pts in remission who are not eligible for hematopoietic stem cell transplant (HSCT). CC-486 is an oral hypomethylating agent that allows for extended dosing schedules ( >7 days [d]/cycle) to sustain therapeutic activity. In the phase III placebo (PBO)-controlled QUAZAR AML-001 trial (NCT01757535), CC-486 maintenance therapy in pts with AML in first remission following IC produced significant improvements in overall and relapse-free survival. Here we report safety and tolerability findings among pt subgroups defined by age at study entry. Methods: Eligible pts were ≥ 55 yrs of age, with de novo or secondary AML, intermediate or poor risk cytogenetics, and ECOG PS ≤ 3; had achieved first CR or CRi after IC ± consolidation; and were not candidates for HSCT. Within 4 mo of CR/CRi, pts were randomized 1:1 to CC-486 300 mg or PBO QD on d 1–14 of repeated 28d Tx cycles. Safety was assessed across 3 age subgroups (≥ 55 to < 65, ≥ 65 to < 75, and ≥ 75 yrs) in pts who received ≥ 1 dose of study drug. Adverse events (AEs) were coded using MedDRA v. 22.0 and graded by NCI-CTCAE v. 4.0. Results: 469 pts ( >99% of all enrolled pts) were evaluable for safety (CC-486 n = 236; PBO n = 233). Median age was 68 yrs (range 55-86). Age distribution was similar between the two Tx arms (Table). Between Tx arms, AE rates within each age stratum were similar to rates in the overall study population. The most common AEs (any grade) with CC-486 were GI events, which were more frequent than in the PBO arm across age groups. Within the CC-486 arm, AE rates were generally consistent across age groups, except for constipation, which was > 20% more frequent in pts aged ≥ 75 yrs, and thrombocytopenia, which was ≥ 20% less frequent in this group (Table). Overall, 13% and 4% of pts in the CC-486 and PBO groups discontinued Tx due to AEs. Conclusions: In QUAZAR AML-001, CC-486 was generally well tolerated in all age groups, including elderly pts aged ≥ 75 yrs. Clinical trial information: NCT01757535 . [Table: see text]
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Affiliation(s)
- Farhad Ravandi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andrew Wei
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Hervé Dombret
- Hôpital Saint-Louis, Assistance Publique–Hôpitaux de Paris (AP-HP) and Institut de Recherche Saint-Louis, Université de Paris, Paris, France
| | | | | | | | | | | | - Paula Marlton
- Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | | | - Valeria Santini
- MDS Unit, Azienda Ospedaliero Universitaria (AOU) Careggi, University of Florence, Florence, Italy
| | | | - Anna Candoni
- Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | | | | | | | | | | | - Gail J. Roboz
- Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY
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29
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Ravandi F, Walter RB, Subklewe M, Buecklein V, Jongen-Lavrencic M, Paschka P, Ossenkoppele GJ, Kantarjian HM, Hindoyan A, Agarwal SK, Dai T, Khaldoyanidi S, Stein AS. Updated results from phase I dose-escalation study of AMG 330, a bispecific T-cell engager molecule, in patients with relapsed/refractory acute myeloid leukemia (R/R AML). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7508] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7508 Background: In this open label phase 1 dose escalation study, safety, tolerability, pharmacokinetics, pharmacodynamics and preliminary efficacy of AMG 330 were evaluated in patients (pts) with R/R AML (NCT#02520427). Methods: AMG 330 was evaluated as a continuous IV (cIV) infusion using a 3+3 design. Response was assessed per revised IWG criteria. Each cycle (2–4 weeks duration) was followed by an infusion-free interval. Eligible pts were ≥18 y/o with > 5% blasts in bone marrow and ≥1 line/s of prior therapy. Results: As of December 10, 2019, 55 pts (median age, 58.0 [18.0–80.0] years) were enrolled in 16 cohorts. AMG 330 was administered on 4 schedules (0–3 dose steps) prior to the target dose (TD, 0.5–720 µg/day). Dose steps were implemented in the dose schedule design based on the adverse event (AE) profile. Across all schedules, 55 (100%) pts reported treatment-emergent AEs (any grade). AMG 330–related AEs reported in 49/55 (89%) pts included cytokine release syndrome (CRS; 67%; ≥ grade 3 in 13%), (60%) and nausea (20%) as the most frequent AEs. CRS was reversible and occurred in a dose/schedule-dependent manner mostly within the first 24 hours of administration of triggering AMG 330 dose. The frequency and severity of CRS correlated with the dose level and leukemic burden at baseline. AMG 330 exhibited dose-dependent increase in steady state exposures over the studied dose range with clinical PK profile consistent with cIV administration. Eight of 42 evaluable pts responded: 3 complete remissions (CR; including 1 CR with negative measurable residual disease reported after data snapshot), 4 CR with incomplete hematologic recovery, and 1 morphologic leukemia free state. Seven responders who achieved CR/CRi received a TD equal or above the minimal efficacious dose of 120 μg/day. Among analyzed CR/CRi responders, 4/6 (67%) had adverse cytogenetic risk profile, 3/6 (50%) had ≥4 lines of prior therapy and all had relapsed disease. Responders had higher AMG 330 exposures and 3 responders treated with ≥600 μg/day TD remain in CR/CRi: 1 patient for > 5 months after cycle 1, 1 patient bridged to hematopoietic stem cell transplant after cycle 4 and 1 patient is in cycle 3. Preliminary response assessment showed a correlation with lower tumor burden at baseline with a trend towards higher CD8+ lymphocyte count and E:T ratio. Conclusions: AMG 330 dosed up to 720 μg/day provided early evidence of acceptable safety profile, drug tolerability and anti-leukemic activity, and supports further dose escalation. Clinical trial information: NCT02520427 .
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roland B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Veit Buecklein
- Department of Internal Medicine III, University Hospital, LMU Munich, Munich, Germany
| | | | | | | | - Hagop M. Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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30
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Dohner H, Wei A, Montesinos P, Dombret H, Ravandi F, Sayar H, Porkka K, Sandhu I, Passamonti F, Pane F, Robak T, Falantes JF, Schuh AC, Ossenkoppele GJ, La Torre I, Skikne B, Kumar K, Dong Q, Beach CL, Roboz GJ. Escalated dosing schedules of CC-486 for patients experiencing first acute myeloid leukemia (AML) relapse: Results from the phase III QUAZAR AML-001 maintenance trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7513 Background: A goal of AML maintenance therapy is to decrease the risk of relapse by suppressing growth of residual leukemic cells post-induction. CC-486 is an oral hypomethylating agent that allows for extended dosing schedules ( >7 days [d]/28d cycle) to sustain therapeutic activity. In the QUAZAR AML-001 trial (NCT01757535), CC-486 maintenance treatment (Tx) significantly prolonged overall (OS) and relapse-free survival vs. placebo (PBO) in pts with AML in first remission following induction chemotherapy (IC), who were not candidates for hematopoietic stem cell transplant (HSCT). Pts initially received CC-486 or PBO for 14d/cycle, but pts who relapsed with 5–15% blasts could receive escalated 21d/cycle dosing. We review outcomes of pts who received 21d dosing in QUAZAR AML-001. Methods: Pts were aged ≥ 55 years, with intermediate- or poor-risk cytogenetics and ECOG PS ≤ 3, and had achieved first CR/CRi after IC ± consolidation. Within 4 mo of CR/CRi, pts were randomized 1:1 to CC-486 300 mg or PBO QD on d 1–14 of 28d Tx cycles. CR/CRi status was assessed every 3 cycles. Pts relapsing with 5%–15% blasts in blood or bone marrow could receive study drug for 21d/cycle at the investigator’s discretion. Tx could continue until > 15% blasts, unacceptable toxicity, or HSCT. Results: 91 patients (CC-486, 51/238 [21%]; PBO, 40/234 [17%]) were assigned to ≥ 1 21d/cycle dosing schedule. Median time to dose escalation was 9.2 mo (range 1.0-52.7) for CC-486 and 6.0 mo (0.5-19.3) for PBO. Median number of 21d dosing cycles was 2.0 (range 1-45) in the CC-486 arm and 2.0 (1-16) in the PBO arm; 43% and 18% of pts, respectively, received > 3 cycles of 21d dosing. Among 78 evaluable pts, 10/43 (23%) CC-486 pts and 4/35 (11%) PBO pts regained CR/CRi (central review) during dose escalation. Median OS from randomization was 22.8 mo vs. 14.6 mo with CC-486 vs. PBO, respectively (HR 0.66 [95%CI 0.42, 1.0]; P = 0.073), and 1-year survival rates were 80.4% vs. 59.5% (+20.9% [95%CI 2.1%, 39.7%]). The most common AEs with first onset during 21d dosing were febrile neutropenia (CC-486 24%, PBO 3%), thrombocytopenia (22%, 23%), anemia (22%, 20%), and neutropenia (20%, 10%). Conclusions: Escalated 21d CC-486 dosing was well tolerated and resulted in prolongation of OS and restoration of remission in approximately one-fourth of pts. Hematologic AEs first reported during escalated dosing in both Tx arms may be due in part to disease relapse. A 21d dosing schedule should be considered for pts receiving CC-486 who experience relapse with 5–15% blasts. Clinical trial information: NCT01757535 .
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Affiliation(s)
| | - Andrew Wei
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Pau Montesinos
- Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Hervé Dombret
- Hôpital Saint-Louis, Assistance Publique–Hôpitaux de Paris (AP-HP) and Institut de Recherche Saint-Louis, Université de Paris, Paris, France
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hamid Sayar
- Indiana University Cancer Center, Indianapolis, IN
| | - Kimmo Porkka
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | | | | | - Fabrizio Pane
- Azienda Ospedaliera Universitaria Federico II, Naples, Italy
| | - Tadeusz Robak
- Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | | | | | | | | | | | | | | | | | - Gail J. Roboz
- Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY
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Agarwal SK, Bhagwat S, Mehta K, Hindoyan A, Stein AS, Ravandi F, Subklewe M, Walter RB, Jongen-Lavrencic M, Ossenkoppele GJ, Paschka P, Khaldoyanidi S, Dutta S, Upreti VV. Characterization of clinical pharmacokinetics and exposure-response relationships of AMG 330, a bispecific CD33 T-cell engager antibody construct, in patients with relapsed/refractory AML. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7536 Background: AMG 330 binds both CD33 and CD3 and redirects T cells toward CD33+ cells leading to T-cell‒mediated cytotoxicity against AML blasts. An ongoing open label phase I dose-escalation study (NCT02520427) has shown preliminary activity and acceptable safety in relapsed or refractory (R/R) acute myeloid leukemia (AML) patients (pts) (Ravandi et al. ASH 2018). Pharmacokinetics and exposure-response (E-R) relationships of AMG 330 were characterized in this trial. Methods: A continuous IV infusion of AMG 330 was evaluated at escalating target doses (range from 0.5 to 720 μg/day) using a 3+3 design with pts receiving step dose/s prior to reaching target doses of ≥ 30 μg/day. Population pharmacokinetics (popPK) using non-linear mixed effects modeling and E-R analyses were conducted to characterize relationships between AMG 330 exposure (steady-state concentration [Css]) at target dose, the baseline tumor burden, clinical response per revised IWG criteria and incidence of cytokine release syndrome (CRS). Results: As of Dec 10, 2019, 55 patients (males, 56.4%; median age, 58.0 [18.0–80.0] years) were enrolled in 16 cohorts. AMG 330 PK was best described by a one-compartment linear PK model. Dose dependent increases were observed in AMG 330 Css exposures. Responders typically showed higher AMG 330 Css than non-responders. Preliminary exploratory analysis indicated that higher AMG 330 exposures, lower baseline leukemic burden in bone marrow and CD33+ AML cells in peripheral blood, and higher baseline Effector:Target cell ratio may be associated with clinical response. Additionally, a positive relationship was observed for AMG 330 exposures and baseline leukemic burden (p < 0.05) with probability of CRS occurrence and severity. Based on the model, at a baseline leukemic burden of 20%, a 240 µg/day target dose is predicted to result in a 28% and 4% probability of developing CRS of grade ≥ 2 and ≥ 3, respectively. Conclusions: Clinical pharmacokinetic profile and E-R relationships of AMG 330 were characterized to identify optimal AMG 330 dosing regimens that minimize the risk for CRS in ongoing and planned clinical investigations. Clinical trial information: NCT02520427 .
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Affiliation(s)
| | | | | | | | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marion Subklewe
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Roland B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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32
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van Alphen C, Cloos J, Beekhof R, Cucchi DGJ, Piersma SR, Knol JC, Henneman AA, Pham TV, van Meerloo J, Ossenkoppele GJ, Verheul HMW, Janssen JJWM, Jimenez CR. Phosphotyrosine-based Phosphoproteomics for Target Identification and Drug Response Prediction in AML Cell Lines. Mol Cell Proteomics 2020; 19:884-899. [PMID: 32102969 PMCID: PMC7196578 DOI: 10.1074/mcp.ra119.001504] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
Acute myeloid leukemia (AML) is a clonal disorder arising from hematopoietic myeloid progenitors. Aberrantly activated tyrosine kinases (TK) are involved in leukemogenesis and are associated with poor treatment outcome. Kinase inhibitor (KI) treatment has shown promise in improving patient outcome in AML. However, inhibitor selection for patients is suboptimal.In a preclinical effort to address KI selection, we analyzed a panel of 16 AML cell lines using phosphotyrosine (pY) enrichment-based, label-free phosphoproteomics. The Integrative Inferred Kinase Activity (INKA) algorithm was used to identify hyperphosphorylated, active kinases as candidates for KI treatment, and efficacy of selected KIs was tested.Heterogeneous signaling was observed with between 241 and 2764 phosphopeptides detected per cell line. Of 4853 identified phosphopeptides with 4229 phosphosites, 4459 phosphopeptides (4430 pY) were linked to 3605 class I sites (3525 pY). INKA analysis in single cell lines successfully pinpointed driver kinases (PDGFRA, JAK2, KIT and FLT3) corresponding with activating mutations present in these cell lines. Furthermore, potential receptor tyrosine kinase (RTK) drivers, undetected by standard molecular analyses, were identified in four cell lines (FGFR1 in KG-1 and KG-1a, PDGFRA in Kasumi-3, and FLT3 in MM6). These cell lines proved highly sensitive to specific KIs. Six AML cell lines without a clear RTK driver showed evidence of MAPK1/3 activation, indicative of the presence of activating upstream RAS mutations. Importantly, FLT3 phosphorylation was demonstrated in two clinical AML samples with a FLT3 internal tandem duplication (ITD) mutation.Our data show the potential of pY-phosphoproteomics and INKA analysis to provide insight in AML TK signaling and identify hyperactive kinases as potential targets for treatment in AML cell lines. These results warrant future investigation of clinical samples to further our understanding of TK phosphorylation in relation to clinical response in the individual patient.
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Affiliation(s)
- Carolien van Alphen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Jacqueline Cloos
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pediatric Oncology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Robin Beekhof
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - David G J Cucchi
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pediatric Oncology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Sander R Piersma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Jaco C Knol
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Alex A Henneman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Thang V Pham
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Johan van Meerloo
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Gert J Ossenkoppele
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Henk M W Verheul
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Jeroen J W M Janssen
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Hematology, De Boelelaan 1117, Amsterdam, Netherlands
| | - Connie R Jimenez
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Oncology, Cancer Center; Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, OncoProteomics Laboratory, Cancer Center Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands.
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33
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Hanekamp D, Snel AN, Kelder A, Scholten WJ, Khan N, Metzner M, Irno-Consalvo M, Sugita M, de Jong A, Oude Alink S, Eidhof H, Wilhelm M, Feuring-Buske M, Slomp J, van der Velden VHJ, Sonneveld E, Guzman M, Roboz GJ, Buccisano F, Vyas P, Freeman S, Bachas C, Ossenkoppele GJ, Schuurhuis GJ, Cloos J. Applicability and reproducibility of acute myeloid leukaemia stem cell assessment in a multi-centre setting. Br J Haematol 2020; 190:891-900. [PMID: 32239670 PMCID: PMC7540683 DOI: 10.1111/bjh.16594] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/02/2020] [Indexed: 01/01/2023]
Abstract
Leukaemic stem cells (LSC) have been experimentally defined as the leukaemia‐propagating population and are thought to be the cellular reservoir of relapse in acute myeloid leukaemia (AML). Therefore, LSC measurements are warranted to facilitate accurate risk stratification. Previously, we published the composition of a one‐tube flow cytometric assay, characterised by the presence of 13 important membrane markers for LSC detection. Here we present the validation experiments of the assay in several large AML research centres, both in Europe and the United States. Variability within instruments and sample processing showed high correlations between different instruments (Rpearson > 0·91, P < 0·001). Multi‐centre testing introduced variation in reported LSC percentages but was found to be below the clinical relevant threshold. Clear gating protocols resulted in all laboratories being able to perform LSC assessment of the validation set. Participating centres were nearly unanimously able to distinguish LSChigh (>0·03% LSC) from LSClow (<0·03% LSC) despite inter‐laboratory variation in reported LSC percentages. This study proves that the LSC assay is highly reproducible. These results together with the high prognostic impact of LSC load at diagnosis in AML patients render the one‐tube LSC assessment a good marker for future risk classification.
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Affiliation(s)
- Diana Hanekamp
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Alexander N Snel
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Angèle Kelder
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Willemijn J Scholten
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Naeem Khan
- Institute of Immunology and Immunotherapy, Department of Clinical Immunology, University of Birmingham, Birmingham, United Kingdom
| | - Marlen Metzner
- Medical Research Council Molecular Hematology Unit, Oxford Centre for Hematology, Oxford BRC, University of Oxford and Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Maria Irno-Consalvo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Mayumi Sugita
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Anja de Jong
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Sjoerd Oude Alink
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Harrie Eidhof
- Department of Clinical Chemistry, Medisch Spectrum Twente/Medlon, Enschede, the Netherlands
| | - Miriam Wilhelm
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | | | - Jennichjen Slomp
- Department of Clinical Chemistry, Medisch Spectrum Twente/Medlon, Enschede, the Netherlands
| | - Vincent H J van der Velden
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Monica Guzman
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Gail J Roboz
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Paresh Vyas
- Medical Research Council Molecular Hematology Unit, Oxford Centre for Hematology, Oxford BRC, University of Oxford and Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Sylvie Freeman
- Institute of Immunology and Immunotherapy, Department of Clinical Immunology, University of Birmingham, Birmingham, United Kingdom
| | - Costa Bachas
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gerrit J Schuurhuis
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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Ossenkoppele GJ, Breems DA, Stuessi G, van Norden Y, Bargetzi M, Biemond BJ, A von dem Borne P, Chalandon Y, Cloos J, Deeren D, Fehr M, Gjertsen B, Graux C, Huls G, Janssen JJJW, Jaspers A, Jongen-Lavrencic M, de Jongh E, Klein SK, van der Klift M, van Marwijk Kooy M, Maertens J, Michaux L, van der Poel MWM, van Rhenen A, Tick L, Valk P, Vekemans MC, van der Velden WJFM, de Weerdt O, Pabst T, Manz M, Löwenberg B. Lenalidomide added to standard intensive treatment for older patients with AML and high-risk MDS. Leukemia 2020; 34:1751-1759. [PMID: 32020044 DOI: 10.1038/s41375-020-0725-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/24/2019] [Accepted: 01/22/2020] [Indexed: 11/09/2022]
Abstract
More effective treatment modalities are urgently needed in patients with acute myeloid leukemia (AML) of older age. We hypothesized that adding lenalidomide to intensive standard chemotherapy might improve their outcome. After establishing a safe lenalidomide, dose elderly patients with AML were randomly assigned in this randomized Phase 2 study (n = 222) to receive standard chemotherapy ("3 + 7") with or without lenalidomide at a dose of 20 mg/day 1-21. In the second cycle, patients received cytarabine 1000 mg/m2 twice daily on days 1-6 with or without lenalidomide (20 mg/day 1-21). The CR/CRi rates in the two arms were not different (69 vs. 66%). Event-free survival (EFS) at 36 months was 19% for the standard arm versus 21% for the lenalidomide arm and overall survival (OS) 35% vs. 30%, respectively. The frequencies and grade of adverse events were not significantly different between the treatment arms. Cardiovascular toxicities were rare and equally distributed between the arms. The results of the present study show that the addition of lenalidomide to standard remission induction chemotherapy does not improve the therapeutic outcome of older AML patients. This trial is registered as number NTR2294 in The NederlandsTrial Register (www.trialregister.nl).
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Affiliation(s)
- G J Ossenkoppele
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands.
| | | | - G Stuessi
- Bellinzona-IOSI, Bellinzona, Switzerland
| | - Y van Norden
- HOVON Data Center, Erasmus MC- Department of Hematology, Rotterdam, The Netherlands
| | - M Bargetzi
- Aarau- Kantonsspital, Aarau, Switzerland
| | - B J Biemond
- Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | | | - Y Chalandon
- University Hospital and University of Geneva, Genève, Switzerland
| | - J Cloos
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands
| | - D Deeren
- Roeselare-AZ Delta, Roeselare, Belgium
| | - M Fehr
- St Gallen-Kantonnsspital, St. Gallen, Switzerland
| | - B Gjertsen
- Haukeland University Hospital, Bergen (N), Norway
| | - C Graux
- Yvoir-MontGodinne, Yvoir, Belgium
| | - G Huls
- University Medical Center, Groningen, Netherlands
| | - J J J W Janssen
- Amsterdam University Medical Cente, location VUMC, Amsterdam, Netherlands
| | - A Jaspers
- Hôpital Citadelle, Liège (B), Belgium
| | | | | | - S K Klein
- Meander Medical Center, Amersfoort, Netherlands
| | | | | | - J Maertens
- Hospital Gasthuisberg, Leuven (B), Belgium
| | - L Michaux
- Center for Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | | | | | - L Tick
- MaximaMC Eindhoven, Eindhoven, Netherlands
| | - P Valk
- Hôpital Citadelle, Liège (B), Belgium
| | | | | | - O de Weerdt
- St Antonius Hospital, Nieuwegein, Netherlands
| | - T Pabst
- Department of Oncology, University Hospital, Inselspital and University of Bern, Bern, Switzerland
| | - M Manz
- University Hospital, Zurich, Switzerland
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35
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Kiesewetter B, Cherny NI, Boissel N, Cerisoli F, Dafni U, de Vries EGE, Ghia P, Gökbuget N, González-Calle V, Huntly B, Jäger U, Latino NJ, Douillard JY, Malcovati L, Mateos MV, Ossenkoppele GJ, Porkka K, Raderer M, Ribera JM, Scarfò L, Wester R, Zygoura P, Sonneveld P. EHA evaluation of the ESMO-Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS v1.1) for haematological malignancies. ESMO Open 2020; 5:e000611. [PMID: 31958292 PMCID: PMC7003483 DOI: 10.1136/esmoopen-2019-000611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Value frameworks in oncology have not been validated for the assessment of treatments in haematological malignancies, but to avoid overlaps and duplications it appears reasonable to build up experience on existing value frameworks, such as the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS). METHODS Here we present the results of the first feasibility testing of the ESMO-MCBS v1.1 for haematological malignancies based on the grading of 80 contemporary studies for acute leukaemia, chronic leukaemia, lymphoma, myeloma and myelodysplastic syndromes. The aims were (1) to evaluate the scorability of data, (2) to evaluate the reasonableness of the generated grades for clinical benefit using the current version and (3) to identify shortcomings in the ESMO-MCBS v1.1 that require amendments to improve the efficacy and validity of the scale in grading new treatments in the management of haematological malignancies. RESULTS In general, the ESMO-MCBS v1.1 was found to be widely applicable to studies in haematological malignancies, generating scores that were judged as reasonable by European Hematology Association (EHA) experts. A small number of studies could either not be graded or were not appropriately graded. The reasons, related to the differences between haematological and solid tumour malignancies, are identified and described. CONCLUSIONS Based on the findings of this study, ESMO and EHA are committed to develop a version of the ESMO-MCBS that is validated for haematological malignancies. This development process will incorporate all of the usual stringencies for accountability of reasonableness that have characterised the development of the ESMO-MCBS including field testing, statistical modelling, evaluation for reasonableness and openness to appeal and revision. Applying such a scale will support future public policy decision-making regarding the value of new treatments for haematological malignancies and will provide insights that could be helpful in the design of future clinical trials.
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Affiliation(s)
- Barbara Kiesewetter
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Nathan I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Nicolas Boissel
- Department of Hematology, Hospital Saint-Louis, Paris, Île-de-France, France
- Adolescent and Young Adult Hematology Unit, Diderot University Paris Faculty of Medicine, Paris, Île-de-France, France
| | - Francesco Cerisoli
- European Hematology Association, Den Haag, Zuid-Holland, The Netherlands
| | - Urania Dafni
- Laboratory of Biostatistics, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
- Frontier Science Foundation-Hellas, Frontier Science Foundation-Hellas, Athens, Greece
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paolo Ghia
- Strategic Research Program on CLL, Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Milano, Lombardia, Italy
- Universita Vita e Salute San Raffaele, Milano, Lombardia, Italy
| | - Nicola Gökbuget
- Department of Hematology/Oncology, Goethe University, Frankfurt am Main, Hessen, Germany
| | - Verónica González-Calle
- Department of Hematology and Instituto de Investigación Biomédica de Salamanca-IBSAL, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Brian Huntly
- Cambridge Stem Cell Institute, Department of Haematology, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Ulrich Jäger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | | | | | - Luca Malcovati
- Department of Molecular Medicine, University of Pavia, Pavia, Lombardia, Italy
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Lombardia, Italy
| | - María-Victoria Mateos
- Department of Hematology and Instituto de Investigación Biomédica de Salamanca-IBSAL, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Kimmo Porkka
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Markus Raderer
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Josep-Maria Ribera
- Clinical Hematology Department, ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain
| | - Lydia Scarfò
- Strategic Research Program on CLL, Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Milano, Lombardia, Italy
- Universita Vita e Salute San Raffaele, Milano, Lombardia, Italy
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
| | - Panagiota Zygoura
- Frontier Science Foundation-Hellas, Frontier Science Foundation-Hellas, Athens, Greece
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
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36
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Abstract
Risk classification and tailoring of treatment are essential for improving outcome for patients with acute myeloid leukemia or high-risk myelodysplastic syndrome. Both patient and leukemia-specific characteristics assessed using morphology, cytogenetics, molecular biology, and multicolor flow cytometry are relevant at diagnosis and during induction, consolidation, and maintenance phases of the treatment. In particular, minimal residual disease (MRD) during therapy has potential as a prognostic factor of outcome, determination of response to therapy, and direction of targeted therapy. MRD can be determined by cell surface markers using multicolor flow cytometry, whereas leukemia-specific translocations and mutations are measured using polymerase chain reaction-based techniques and recently using next-generation sequencing. All these methods of MRD detection have their (dis)advantages, and all need to be standardized, prospectively validated, and improved to be used for uniform clinical decision making and a potential surrogate end point for clinical trials testing novel treatment strategies. Important issues to be solved are time point of MRD measurement and threshold for MRD positivity. MRD is used for stem cell transplantation (SCT) selection in the large subgroup of patients with an intermediate risk profile. Patients who are MRD positive will benefit from allo-SCT. However, MRD-negative patients have a better chance of survival after SCT. Therefore, it is debated whether MRD-positive patients should be extensively treated to become MRD negative before SCT. Either way, accurate monitoring of potential residual or upcoming disease is mandatory. Tailoring therapy according to MRD monitoring may be the most successful way to provide appropriate specifically targeted, personalized treatment.
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Affiliation(s)
- Jacqueline Cloos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands; and
| | - Gert J Ossenkoppele
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands; and
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
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37
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Verhagen HJMP, van Gils N, Martiañez T, van Rhenen A, Rutten A, Denkers F, de Leeuw DC, Smit MA, Tsui ML, de Vos Klootwijk LLE, Menezes RX, Çil M, Roemer MGM, Vermue E, Heukelom S, Zweegman S, Janssen JJWM, Ossenkoppele GJ, Schuurhuis GJ, Smit L. IGFBP7 Induces Differentiation and Loss of Survival of Human Acute Myeloid Leukemia Stem Cells without Affecting Normal Hematopoiesis. Cell Rep 2019; 25:3021-3035.e5. [PMID: 30540936 DOI: 10.1016/j.celrep.2018.11.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 10/09/2018] [Accepted: 11/14/2018] [Indexed: 12/21/2022] Open
Abstract
Leukemic stem cells (LSCs) are thought to be the major cause of the recurrence of acute myeloid leukemia (AML) due to their potential for self-renewal. To identify therapeutic strategies targeting LSCs, while sparing healthy hematopoietic stem cells (HSCs), we performed gene expression profiling of LSCs, HSCs, and leukemic progenitors all residing within the same AML bone marrow and identified insulin-like growth factor-binding protein 7 (IGFBP7) as differentially expressed. Low IGFBP7 is a feature of LSCs and is associated with reduced chemotherapy sensitivity. Enhancing IGFBP7 by overexpression or addition of recombinant human IGFBP7 (rhIGFBP7) resulted in differentiation, inhibition of cell survival, and increased chemotherapy sensitivity of primary AML cells. Adding rhIGFBP7 reduced leukemic stem and/or progenitor survival and reversed a stem-like gene signature, but it had no influence on normal hematopoietic stem cell survival. Our data suggest a potential clinical utility of the addition of rhIGFBP7 to current chemotherapy regimens to decrease AML relapse rates.
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Affiliation(s)
- Han J M P Verhagen
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Noortje van Gils
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Tania Martiañez
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Anna van Rhenen
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Arjo Rutten
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Fedor Denkers
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - David C de Leeuw
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Marjon A Smit
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Mei-Ling Tsui
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Louise L E de Vos Klootwijk
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Renee X Menezes
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Meyram Çil
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Margaretha G M Roemer
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Eline Vermue
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Stan Heukelom
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Gerrit Jan Schuurhuis
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Linda Smit
- Department of Hematology, Cancer Center Amsterdam (CCA), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands.
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38
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Cucchi DGJ, Bachas C, Klein K, Huttenhuis S, Zwaan CM, Ossenkoppele GJ, Janssen JMWM, Kaspers GL, Cloos J. TP53 mutations and relevance of expression of TP53 pathway genes in paediatric acute myeloid leukaemia. Br J Haematol 2019; 188:736-739. [PMID: 31588562 DOI: 10.1111/bjh.16229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/14/2019] [Indexed: 12/12/2022]
Abstract
Limited data are available on the incidence and impact of TP53 alterations and TP53 pathway deregulation in paediatric acute myeloid leukaemia (AML). We analysed TP53 alterations in bone marrow samples of 229 patients with de novo paediatric AML, and detected heterozygous missense exon mutations in two patients (1%) and 17p deletions of the TP53 gene in four patients (2%). These patients more frequently had complex karyotype (50% vs. 4%, P = 0·002) or adverse cytogenetic abnormalities, including complex karyotype (67% vs. 17%, P = 0·013), compared to TP53 wild-type. Differential expression of TP53 pathway genes was associated with poor survival, indicating a role for TP53 regulators and effector genes.
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Affiliation(s)
- David G J Cucchi
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands.,Department of Haematology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Costa Bachas
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands.,Department of Haematology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Kim Klein
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Sander Huttenhuis
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Christian M Zwaan
- Department of Paediatric Oncology/Haematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Gert J Ossenkoppele
- Department of Haematology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Jeroen M W M Janssen
- Department of Haematology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
| | - Gertjan L Kaspers
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands.,Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Jacqueline Cloos
- Department of Paediatric Oncology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands.,Department of Haematology, Cancer Centre Amsterdam, Amsterdam UMC, VUMC, Amsterdam, The Netherlands
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39
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Schuurhuis GJ, Ossenkoppele GJ, Kelder A, Cloos J. Measurable residual disease in acute myeloid leukemia using flow cytometry: approaches for harmonization/standardization. Expert Rev Hematol 2019; 11:921-935. [PMID: 30466339 DOI: 10.1080/17474086.2018.1549479] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Measurable residual disease (MRD) in acute myeloid leukemia (AML) is a rapidly evolving area with many institutes embarking on it, both in academic and pharmaceutical settings. However, there is a multitude of approaches to design, perform, and report flow cytometric MRD. Together with the long-term experience needed, this makes flow cytometric MRD in AML nonstandardized and time-consuming. Areas covered: This paper briefly summarizes critical issues, like sample preparation and transport, markers and fluorochromes of choice, but in particular focuses on the main issues, which includes specificity and sensitivity, hereby providing a new model that may circumvent the main disadvantages of the present approaches. New approaches that may add to the value of flow cytometric MRD includes assessment of leukemia stem cells, MRD in peripheral blood, and approaches to use multidimensional image analysis. Expert commentary: MRD in AML requires standardization/harmonization on many aspects, for which the present paper offers possible guidelines.
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Affiliation(s)
- Gerrit J Schuurhuis
- a Department of Hematology , VU University Medical Center , Amsterdam , Netherlands
| | - Gert J Ossenkoppele
- a Department of Hematology , VU University Medical Center , Amsterdam , Netherlands
| | - Angèle Kelder
- a Department of Hematology , VU University Medical Center , Amsterdam , Netherlands
| | - Jacqueline Cloos
- a Department of Hematology , VU University Medical Center , Amsterdam , Netherlands
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40
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de Jong G, Janssen JJWM, Biemond BJ, Zeerleder SS, Ossenkoppele GJ, Visser O, Nur E, Meijer E, Hazenberg MD. Survival of early posthematopoietic stem cell transplantation relapse of myeloid malignancies. Eur J Haematol 2019; 103:491-499. [PMID: 31411761 PMCID: PMC6851577 DOI: 10.1111/ejh.13315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
Abstract
Objective Relapse of AML after allogeneic hematopoietic stem cell transplantation (HSCT) has a poor prognosis, and standard of care therapy is lacking. Early (<6 months) relapse is associated with dismal outcome, while the majority of relapses occur early after transplantation. A more precise indication which patients could benefit from reinduction therapy is warranted. Methods We retrospectively analyzed outcomes of 83 patients with postallogeneic HSCT relapse. Patients were divided based on intention to treat (curative vs supportive care). Results Of the 50 patients treated with curative intent, 44% reached complete remission (CR) upon reinduction chemotherapy, and of these patients, 50% survived. Two survivors reached CR after immunotherapy (donor lymphocyte infusion (DLI), without reinduction chemotherapy). Sixty‐nine percent of the survivors had received high‐intensity cytarabine treatment, followed by immunologic consolidation. Relapse <3 months after transplantation was predictive for adverse survival (P = .004), but relapse <6 months was not. In fact, >50% of the survivors had a relapse <6 months. Conclusion We confirmed the dismal prognosis of postallogeneic HSCT relapse. Importantly, our data demonstrate that patients fit enough to receive high‐dose chemotherapy, even when relapse occurred <6 months, had the best chance to obtain durable remissions, in particular when immunologic consolidation was performed after reaching CR.
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Affiliation(s)
- Greta de Jong
- Department of Hematology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,AIMM Therapeutics, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen J W M Janssen
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sacha S Zeerleder
- Department of Hematology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Immunopathology, Sanquin, Amsterdam, The Netherlands.,Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Gert J Ossenkoppele
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Otto Visser
- Department of Hematology, Oncology Center, Isala Klinieken Zwolle, Zwolle, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ellen Meijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Mette D Hazenberg
- Department of Hematology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
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41
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Freeman SD, Hills RK, Russell NH, Cloos J, Kelder A, Ossenkoppele GJ, Schuurhuis GJ. Induction response criteria in acute myeloid leukaemia: implications of a flow cytometric measurable residual disease negative test in refractory adults. Br J Haematol 2019; 186:130-133. [PMID: 30520018 DOI: 10.1111/bjh.15698] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Robert K Hills
- Centre for Trials Research Cardiff University, Cardiff, UK
| | | | - Jacqueline Cloos
- Amsterdam UMC, Location VUMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Angèle Kelder
- Amsterdam UMC, Location VUMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gert J Ossenkoppele
- Amsterdam UMC, Location VUMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerrit J Schuurhuis
- Amsterdam UMC, Location VUMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
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42
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van Spronsen MF, Westers TM, Lissenberg-Witte BI, Wondergem M, Ossenkoppele GJ, van de Loosdrecht AA. The non-erythroid myeloblast count rule in myelodysplastic syndromes: fruitful or futile? Haematologica 2019; 104:e547-e550. [PMID: 31004031 DOI: 10.3324/haematol.2018.212563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Margot F van Spronsen
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam
| | - Theresia M Westers
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Biostatistics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mariëlle Wondergem
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam
| | - Arjan A van de Loosdrecht
- Department of Hematology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Cancer Center Amsterdam
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43
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Moshaver B, Wouters RF, Kelder A, Ossenkoppele GJ, Westra GAH, Kwidama Z, Rutten AR, Kaspers GJL, Zweegman S, Cloos J, Schuurhuis GJ. Relationship between CD34/CD38 and side population (SP) defined leukemia stem cell compartments in acute myeloid leukemia. Leuk Res 2019; 81:27-34. [PMID: 31002948 DOI: 10.1016/j.leukres.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022]
Abstract
Leukemic stem cells (LSCs), defined by CD34/CD38 expression, are believed to be essential for leukemia initiation and therapy resistance in acute myeloid leukemia. In addition, the side population (SP), characterized by high Hoechst 33342 efflux, reflecting therapy resistance, has leukemia initiating ability. The purpose of this study is, in both CD34-positive and CD34-negative AML, to integrate both types of LSC compartment into a new more restricted definition. Different CD34/CD38/SP defined putative LSC and normal hematopoietic compartments, with neoplastic or normal nature, respectively, were thus identified after cell sorting, and confirmed by FISH/PCR. Stem cell activity was assessed in the long-term liquid culture stem cell assay. SP fractions harbored the strongest functional stem cell activity in both normal and neoplastic cells in both CD34-positive and CD34-negative AML. Overall, inclusion of SP fraction decreased the size of the putative CD34/CD38 defined LSC compartment by a factor >500. For example, for the important CD34+CD38- LSC compartment, the median SP/CD34+CD38- frequency was 5.1 per million WBC (CD34-positive AML), and median SP/CD34-CD38+ frequency (CD34-negative AML) was 1796 per million WBC. Improved detection of LSC may enable identification of therapy resistant clones, and thereby identification of novel LSC specific, HSC sparing, therapies.
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Affiliation(s)
- Bijan Moshaver
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Rolf F Wouters
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands; Department of Pediatric Oncology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Angèle Kelder
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Guus A H Westra
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Zinia Kwidama
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands; Department of Pediatric Oncology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Arjo R Rutten
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Gert J L Kaspers
- Department of Pediatric Oncology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands; Department of Pediatric Oncology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Gerrit J Schuurhuis
- Department of Hematology, Cancer Center Amsterdam, VU University Medical Center, 1081HV Amsterdam, the Netherlands.
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44
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Reedijk AMJ, Klein K, Coebergh JWW, Kremer LC, Dinmohamed AG, de Haas V, Versluijs AB, Ossenkoppele GJ, Beverloo HB, Pieters R, Zwaan CM, Kaspers GJL, Karim-Kos HE. Improved survival for children and young adolescents with acute myeloid leukemia: a Dutch study on incidence, survival and mortality. Leukemia 2018; 33:1349-1359. [PMID: 30568171 DOI: 10.1038/s41375-018-0314-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/03/2018] [Accepted: 10/29/2018] [Indexed: 01/08/2023]
Abstract
Variation in survival of pediatric acute myeloid leukemia (pAML) over time and between Western European countries exists. The aim of the current study is to assess the progress made for the Dutch pAML population (0-17 years) during 1990-2015, based on trends in incidence, survival and mortality. Data from the population-based Netherlands Cancer Registry were merged with leukemia-related characteristics and treatment specifics from the Dutch Childhood Leukemia Study Group (Dutch Childhood Oncology Group (DCOG) from 2002 onwards). Mortality data (1980-2016) were obtained from the cause of death registry of Statistics Netherlands. Trend analyses were performed over time and by treatment protocol. Between 1990 and 2015, a total of 635 children aged 0-17 years were diagnosed with AML for an average of 25 patients (range 18-36) per year. There was a slight increase in the incidence at age 1-4 years (average annual percentage change (AAPC) of +2.2% per year (95% CI 0.8-3.5, p < 0.01)). Overall, the 5-year survival significantly improved over the past 26 years and nearly doubled from 40% in the early 1990s to 74% in 2010-2015. Multivariable analysis showed a 49% reduction in risk of death for pAML patients treated according to the latest DB-AML 01 protocol (p = 0.03). The continuing decrease of mortality (AAPC -2.8% per year (95% CI -4.1 to -1.5)) supports the conclusion of true progress against pAML in the Netherlands.
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Affiliation(s)
- A M J Reedijk
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - K Klein
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - J W W Coebergh
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L C Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - A G Dinmohamed
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - V de Haas
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Dutch Childhood Oncology Group, Utrecht, The Netherlands
| | - A B Versluijs
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - G J Ossenkoppele
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - H B Beverloo
- Department of Clinical Genetics, Erasmus University Medical Center/Dutch Working Group Hemato-oncological Genome Diagnostics, Rotterdam, The Netherlands
| | - R Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - C M Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, Erasmus University Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - G J L Kaspers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands.,Dutch Childhood Oncology Group, Utrecht, The Netherlands
| | - H E Karim-Kos
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
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45
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Zeijlemaker W, Grob T, Meijer R, Hanekamp D, Kelder A, Carbaat-Ham JC, Oussoren-Brockhoff YJM, Snel AN, Veldhuizen D, Scholten WJ, Maertens J, Breems DA, Pabst T, Manz MG, van der Velden VHJ, Slomp J, Preijers F, Cloos J, van de Loosdrecht AA, Löwenberg B, Valk PJM, Jongen-Lavrencic M, Ossenkoppele GJ, Schuurhuis GJ. CD34 +CD38 - leukemic stem cell frequency to predict outcome in acute myeloid leukemia. Leukemia 2018; 33:1102-1112. [PMID: 30542144 DOI: 10.1038/s41375-018-0326-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/07/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022]
Abstract
Current risk algorithms are primarily based on pre-treatment factors and imperfectly predict outcome in acute myeloid leukemia (AML). We introduce and validate a post-treatment approach of leukemic stem cell (LSC) assessment for prediction of outcome. LSC containing CD34+CD38- fractions were measured using flow cytometry in an add-on study of the HOVON102/SAKK trial. Predefined cut-off levels were prospectively evaluated to assess CD34+CD38-LSC levels at diagnosis (n = 594), and, to identify LSClow/LSChigh (n = 302) and MRDlow/MRDhigh patients (n = 305) in bone marrow in morphological complete remission (CR). In 242 CR patients combined MRD and LSC results were available. At diagnosis the CD34+CD38- LSC frequency independently predicts overall survival (OS). After achieving CR, combining LSC and MRD showed reduced survival in MRDhigh/LSChigh patients (hazard ratio [HR] 3.62 for OS and 5.89 for cumulative incidence of relapse [CIR]) compared to MRDlow/LSChigh, MRDhigh/LSClow, and especially MRDlow/LSClow patients. Moreover, in the NPM1mutant positive sub-group, prognostic value of golden standard NPM1-MRD by qPCR can be improved by addition of flow cytometric approaches. This is the first prospective study demonstrating that LSC strongly improves prognostic impact of MRD detection, identifying a patient subgroup with an almost 100% treatment failure probability, warranting consideration of LSC measurement incorporation in future AML risk schemes.
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Affiliation(s)
- Wendelien Zeijlemaker
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tim Grob
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rosa Meijer
- Clinical trial Center- HOVON data center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diana Hanekamp
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Angèle Kelder
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jannemieke C Carbaat-Ham
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Alexander N Snel
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Dennis Veldhuizen
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Willemijn J Scholten
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Dimitri A Breems
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Thomas Pabst
- Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Markus G Manz
- Department of Hematology, University and University Hospital Zürich, Zürich, Switzerland
| | | | - Jennichjen Slomp
- Department of Clinical Chemistry, Medisch Spectrum Twente/Medlon, Enschede, The Netherlands
| | - Frank Preijers
- Department of Laboratory Medicine - Laboratory for Hematology, Radboud University Nijmegen Medical Center, RUNMC, Nijmegen, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Arjan A van de Loosdrecht
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerrit J Schuurhuis
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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46
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Kalin B, Pijnappel EN, van Gelder M, Visser O, van de Loosdrecht AA, Ossenkoppele GJ, Cornelissen JJ, Dinmohamed AG, Jongen-Lavrencic M. Intensive treatment and trial participation in elderly acute myeloid leukemia patients: A population-based analysis in The Netherlands. Cancer Epidemiol 2018; 57:90-96. [DOI: 10.1016/j.canep.2018.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 12/22/2022]
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47
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Morsink LM, Walter RB, Ossenkoppele GJ. Prognostic and therapeutic role of CLEC12A in acute myeloid leukemia. Blood Rev 2018; 34:26-33. [PMID: 30401586 DOI: 10.1016/j.blre.2018.10.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/17/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
CLEC12A has recently been identified as an antigen, expressed on leukemic stem cells and leukemic blasts. Given the fact that this expression profile seems stable throughout diagnosis, treatment and relapse on leukemic blasts and leukemic stem cells, CLEC12A can be considered a highly potent and reliable marker for the detection of measurable residual disease and therefore applicable for risk stratification and prognostication in AML. Low CLEC12A expression on leukemic blasts seems to be independently associated with lower likelihood of achieving complete remission after 1 cycle of induction chemotherapy, shorter event free survival, as well as overall survival, indicating potential prognostic properties of CLEC12A expression itself. Lack of expression on the normal hematopoietic stem and progenitor cells, in contrast to CD123 and CD33, might result in less toxicity regarding cytopenias, making CLEC12A an interesting target for innovating immunotherapies, including monoclonal and bispecific antibodies, antibody-drug conjugates and CAR-T cells therapy.
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Affiliation(s)
- Linde M Morsink
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
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48
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Naik J, Themeli M, de Jong-Korlaar R, Ruiter RWJ, Poddighe PJ, Yuan H, de Bruijn JD, Ossenkoppele GJ, Zweegman S, Smit L, Mutis T, Martens ACM, van de Donk NWCJ, Groen RWJ. CD38 as a therapeutic target for adult acute myeloid leukemia and T-cell acute lymphoblastic leukemia. Haematologica 2018; 104:e100-e103. [PMID: 30190344 DOI: 10.3324/haematol.2018.192757] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Jyoti Naik
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Maria Themeli
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Regina de Jong-Korlaar
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Ruud W J Ruiter
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Pino J Poddighe
- Department of Clinical Genetics, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Huipin Yuan
- Kuros Biosciences BV, Bilthoven, the Netherlands
| | - Joost D de Bruijn
- Kuros Biosciences BV, Bilthoven, the Netherlands.,The School of Engineering and Materials Science, Queen Mary University of London, UK
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Linda Smit
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Tuna Mutis
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Anton C M Martens
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
| | - Richard W J Groen
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, the Netherlands
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49
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van de Loosdrecht AA, van Wetering S, Santegoets SJAM, Singh SK, Eeltink CM, den Hartog Y, Koppes M, Kaspers J, Ossenkoppele GJ, Kruisbeek AM, de Gruijl TD. A novel allogeneic off-the-shelf dendritic cell vaccine for post-remission treatment of elderly patients with acute myeloid leukemia. Cancer Immunol Immunother 2018; 67:1505-1518. [PMID: 30039426 PMCID: PMC6182404 DOI: 10.1007/s00262-018-2198-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 06/29/2018] [Indexed: 01/31/2023]
Abstract
In elderly acute myeloid leukemia (AML) patients post-remission treatment options are associated with high comorbidity rates and poor survival. Dendritic cell (DC)-based immunotherapy is a promising alternative treatment strategy. A novel allogeneic DC vaccine, DCP-001, was developed from an AML-derived cell line that uniquely combines the positive features of allogeneic DC vaccines and expression of multi-leukemia-associated antigens. Here, we present data from a phase I study conducted with DCP-001 in 12 advanced-stage elderly AML patients. Patients enrolled were in complete remission (CR1/CR2) (n = 5) or had smoldering disease (n = 7). All patients were at high risk of relapse and ineligible for post-remission intensification therapies. A standard 3 + 3 dose escalation design with extension to six patients in the highest dose was performed. Patients received four biweekly intradermal DCP-001 injections at different dose levels (10, 25, and 50 million cells DCP-001) and were monitored for clinical and immunological responses. Primary objectives of the study (feasibility and safety) were achieved with 10/12 patients completing the vaccination program. Treatment was well tolerated. A clear-cut distinction between patients with and without detectable circulating leukemic blasts during the vaccination period was noted. Patients with no circulating blasts showed an unusually prolonged survival [median overall survival 36 months (range 7–63) from the start of vaccination] whereas patients with circulating blasts, died within 6 months. Long-term survival was correlated with maintained T cell levels and induction of multi-functional immune responses. It is concluded that DCP-001 in elderly AML patients is safe, feasible and generates both cellular and humoral immune responses.
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Affiliation(s)
- Arjan A van de Loosdrecht
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | | | - Saskia J A M Santegoets
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Corien M Eeltink
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Yvonne den Hartog
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Malika Koppes
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jorn Kaspers
- DCPrime BV, Galileiweg 8, 2333 BD, Leiden, The Netherlands
| | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | | | - Tanja D de Gruijl
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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50
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Verhagen HJ, Gils NV, Rhenen AV, Rutten A, Smit M, Tsui ML, Klootwijk LLDV, Menezes RX, Cil M, Roemer MG, Brocco F, Denkers F, Vermue E, Heukelom S, Zweegman S, Janssen JJ, Ossenkoppele GJ, Schuurhuis GJ, Smit L. Abstract 1114: IGFBP7 reduces acute myeloid leukemia stem cell survival without affecting normal hematopoiesis. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-1114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Only 30-40% of acute myeloid leukemia (AML) patients survive five years after diagnosis. This poor prognosis is mainly caused by treatment failure due to chemotherapy resistance and relapse. Leukemic stem cells (LSCs) are thought to be the major determinants of AML relapse due their potential for self-renewal and chemotherapy resistance. It has been demonstrated that LSC frequency and expression of LSC gene expression signatures is highly predictive of therapy failure in AML patients, indicating the clinical importance of LSCs. LSCs co-reside with residual normal hematopoietic stem cells (HSCs) in the diseased bone marrow. Increasing the dose of chemotherapy might eliminate LSCs, however will inevitable result in non-specific elimination of HSCs, delaying or preventing recovery of normal hematopoiesis after treatment. To significantly improve AML patients outcome, there is an urgent need for identification of alternative therapies that specifically eliminate LSCs while sparing HSC. We generated gene expression profiles of HSCs, LSCs and leukemic progenitors all derived from the same AML bone marrow and identified insulin growth factor binding protein 7 (IGFBP7) as one of the top differentially expressed genes. We found that low IGFBP7 is a feature of LSCs, associated with reduced chemotherapy sensitivity and that IGFBP7 is frequently downregulated at relapse as compared to AML diagnosis. Together, these results suggest that there is a survival advantage of IGFBP7low AML cells during chemotherapy treatment. To test whether increasing IGFBP7 levels might be a strategy to deplete leukemic (stem) cells, we overexpressed IGFBP7 or added recombinant human IGFBP7 (rhIGFBP7) to primary AML cells. Strikingly, IGFBP7 overexpression or addition of rhIGFBP7 led to induction of differentiation and cell death in AML patient cells. Moreover, rhIGFBP7 reduces leukemic engraftment in an AML xenograft mouse model, reverses a stem-like gene signature, and inhibits AML blast and leukemic stem/progenitor cell survival in vitro and in vivo, while it had no influence on normal hematopoietic (stem) cell survival. Our findings define an association between chemotherapy sensitivity and IGFBP7 expression levels in primary AML cells, and indicate that treatment of AML patients with a combination of rhIGFBP7 and chemotherapy might reduce AML residual disease and LSC survival.
Citation Format: Han J. Verhagen, Noortje van Gils, Anna van Rhenen, Arjo Rutten, Marjon Smit, Mei-Ling Tsui, Louise L. de Vos Klootwijk, Renee X. Menezes, Meyram Cil, Margaretha G. Roemer, Fabio Brocco, Fedor Denkers, Eline Vermue, Stan Heukelom, Sonja Zweegman, Jeroen J. Janssen, Gert J. Ossenkoppele, Gerrit Jan Schuurhuis, Linda Smit. IGFBP7 reduces acute myeloid leukemia stem cell survival without affecting normal hematopoiesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1114.
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Affiliation(s)
| | | | | | - Arjo Rutten
- VU University Medical Center, Amsterdam, Netherlands
| | - Marjon Smit
- VU University Medical Center, Amsterdam, Netherlands
| | - Mei-Ling Tsui
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | - Meyram Cil
- VU University Medical Center, Amsterdam, Netherlands
| | | | - Fabio Brocco
- VU University Medical Center, Amsterdam, Netherlands
| | - Fedor Denkers
- VU University Medical Center, Amsterdam, Netherlands
| | - Eline Vermue
- VU University Medical Center, Amsterdam, Netherlands
| | - Stan Heukelom
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | | | | | - Linda Smit
- VU University Medical Center, Amsterdam, Netherlands
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