Imatinib mesylate therapy in patients of chronic myeloid leukemia with Philadelphia chromosome positive: an experience from eastern India

The prevalence of hepatic and thyroid toxicity associated with imatinib treatment of chronic myeloid leukaemia: a systematic review

BACKGROUND

Imatinib, a potent inhibitor of targeted protein tyrosine kinases, treats chronic myeloid leukaemia (CML). Data on imatinib-associated changes in hepatic and thyroid functions are limited and conflicting.

AIM

To report the prevalence of hepatic and thyroid toxicity associated with the use of imatinib in CML patients.

METHOD

Articles for the systematic review were selected from electronic databases (PubMed, CINALH, Web of Science). Readily accessible peer-reviewed full articles in English published 1st January 2000 to 18th July 2023 were included. The search terms included combinations of: imatinib, CML, liver toxicity, hepatic toxicity, thyroid toxicity. Screening of titles, abstracts, full text articles was conducted independently by two reviewers. Inclusions and exclusions were recorded following PRISMA guidelines. Detailed reasons for exclusion were recorded. Included articles were critically appraised.

RESULTS

Ten thousand one hundred and twenty-three CML patients were reported in the 82 included studies corresponding to 21 case reports, 2 case series, 39 clinical trials and 20 observational studies were selected. Excluding case studies/reports, 1268 (12.6%; n = 1268/10046) hepatotoxicity adverse events were reported, of which 64.7% were rated as mild grade I & II adverse events, 363 (28.6%) as severe, grade III and IV adverse events; some led to treatment discontinuation, liver transplantation and fatal consequences. Twenty (35.1%) studies reported discontinuation of imatinib treatment due to the severity of hepatic toxicity. Fourteen (8.4%, n = 14/167) thyroid dysfunction adverse events were reported.

CONCLUSION

High frequency of mild and severe hepatotoxicity, associated with imatinib in CML patients, was reported in the published literature. Low numbers of mild and manageable thyroid toxicity events were reported.

Efficacy and safety profile of generic imatinib in patients with newly diagnosed chronic myeloid leukemia-chronic phase: sharing experience of a hemato-oncology center from eastern India

In India, CML is the commonest adult leukemia. Imatinib is the gold standard for frontline treatment of newly diagnosed CML-CP patients. The present study was conducted to assess the efficacy and safety of generic imatinib in newly diagnosed CML-CP patients. In this prospective study, 76 newly diagnosed CML-CP patients received generic imatinib. They were monitored as per the ELN2013 recommendation. Karyotyping and BCR-ABL transcript level were done at specified time points. Adverse effects, if any, were documented as per the NCI-CTCAE criteria v4.03. Statistical analysis was done using standard methods. A total of 76 patients included in the study; median age was 36 years. The most common (71%) presenting symptom was fatigue; splenomegaly was found in all patients. CHR was achieved in 97% cases. At 3 months, 64.5% patients achieved ERM. At 6 months, CCyR and MCyR had seen in 65% and 68% cases, respectively. MMR achieved at 12 months in 44% cases. Most common hematological and non-hematological toxicity were anemia and skin changes seen in 89.5% and 71% cases, respectively. With generic imatinib therapy, the results of treatment outcome and safety profile were comparable with original imatinib. The added advantage was gross reduction in cost of therapy meeting unmet needs in CML patients in countries with resource constraints.

Summary of the published Indian data on chronic myeloid leukemia

Chronic myelogenous leukemia (LML) was recognized as a distinct entity in the mid-1800s. Since Nowell and Hunagerford initiated their research on CML in1960 our understanding in CML has been increasing. Imatinib became the preferred treatment from 2000 onwards as a result of its unprecedented success. The lack of structured Indian data on CML led to the formation of a CML data cansortuim which invited CML data albiet retro spartive form around the country including major cancer service providers both government and private. We provide a summary of published Indian data on CML here.

Advanced Ovarian Cancer Displays Functional Intratumor Heterogeneity That Correlates to Ex Vivo Drug Sensitivity

Introduction

Epithelial ovarian cancer is recognized to be heterogeneous but is currently treated with a single treatment strategy. Successful patient stratification of emerging chemotherapy agents is dependent upon the availability of reliable biomarkers indicative of the entire tumor.

Aim

The aim of this study was to evaluate intertumor and intratumor heterogeneity within a series of epithelial ovarian cancer using homologous recombination (HR) DNA repair status.

Methods

Primary cultures generated from ascites and solid tumor from multiple intra-abdominal sites were characterized by their morphology and expression of protein markers. Results were compared with Formalin fixed paraffin embedded tissue pathology.

Homologous recombination function was determined by quantification of nuclear Rad51 foci. Growth inhibition (sulforhodamine B) assays were used to calculate the GI50 for cisplatin and rucaparib.

Results

Ascites with matched solid tumor were cultured from 25 patients.

Concordance in functional HR status between ascites and solid tumor subcultures was seen in only 13 (52%) of 25 patients. Heterogeneity in HR status was seen even in patients with homogeneous histological subtype. Homologous recombination defective cultures were significantly more sensitive to cisplatin and rucaparib.

Additionally, intertumor and intratumor heterogeneity was seen between the expression of epithelial and ovarian markers (EpCAM, cytokeratin, CA125, MOC-31, and vimentin). There was no relationship between heterogeneity of HR functional status and antigen expression.

Conclusions

Intertumor and intratumor functional HR heterogeneity exists that cannot be detected using histological classification. This has implications for biomarker-directed treatment.

Overcoming therapy failure in elderly patients with chronic myeloid leukemia

SUMMARY 

Chronic myeloid leukemia (CML) affects mainly older adults, as median age at diagnosis is 60–65 years. For a long time, survival of elderly CML patients has been shorter compared with younger patients. With the advent of the first tyrosine kinase inhibitor (TKI), imatinib, long-term outcome has significantly improved, including in the elderly, with rates of cytogenetic and molecular responses roughly equal to those attained in the young, as well as manageable toxicity. More recently, second-generation (dasatinib, nilotinib and bosutinib) and third-generation (ponatinib) TKIs were employed in CML patients failing imatinib or other front-line treatments. Despite a shorter follow-up, these TKIs showed remarkable activity in elderly patients. This review focuses on the therapeutic strategies to prevent and overcome treatment failure in elderly CML patients.

Response to tyrosine kinase inhibitors in chronic myeloid leukemia: experience from a west Asian developing country

Tyrosine Kinase inhibitors (TKIs) have dramatically changed the prospects for patients with chronic myeloid leukemia (CML); however, information on CML and response to TKIs from Asia are limited, particularly from West Asia, including Iraq. To address the latter issue we evaluated and monitored a cohort of 108 Iraqi patients diagnosed as chronic phase-CML, enrolled in a government-sponsored national program. The patients were all treated initially by imatinib mesylate. Ninety-two percent of patients had a complete hematological response, 38% had a major molecular response, while 79% had a major cytogenetic response after a median follow-up of 35.7 months. The 3-year Event-Free, Progression-Free, and Overall survival rates were 79.6, 87 and 98.1%, respectively. A total of 26 patients (24.1%) were shifted to an alternative TKI (Nilotinib). After one year of therapy in seventeen of the latter patients, 24% had major molecular response. In conclusion, our results compare favorably with those reported from the West and some Asian countries, and have demonstrated the importance of molecular as well as cytogenetic monitoring, and confirmed the relative success of the national CML program in our country.

Importance of early and deeper responses to long-term survival in CML patients: Implications of BCR-ABL testing in management of CML in Indian setting

The prognosis of patients with chronic myeloid leukemia (CML) has changed radically since the advent of imatinib mesylate, a selective inhibitor of BCR-ABL tyrosine kinase. Shortly thereafter, more potent BCR-ABL inhibitors (dasatinib and nilotinib) were introduced for use in patients resistant to or intolerant of imatinib. All three drugs are now approved for initial therapy for chronic phase CML. Response to tyrosine kinase inhibitor (TKI) treatment is assessed with standardized quantitative reverse transcriptase polymerase chain reaction (Q-RTPCR) and/or cytogenetics at 3, 6 and 12 months. Clinical trials have clearly demonstrated that early and deeper cytogenetic and molecular response to TKI therapy is associated with lower rate of disease progression and improved long-term outcomes. In recent times, molecular response as determined by BCR-ABL transcript levels at defined time points is rapidly gaining popularity as a predictive marker for subsequent outcomes in CML. Optimal response is defined as BCR-ABL transcript levels of ≤10% at 3 months, <1% at 6 months, and ≤0.1% from 12 months onward while >10% at 6 months and >1% from 12 months onward define failure. Patients who do not achieve molecular milestones at 3 or 6 months with 3 months being highly predictive are less likely to achieve cytogenetic responses eventually; early identification of such patients who have a low probability of achieving an adequate response are thus candidates for alternative treatment. Review of literature by electronic search of MEDline, Google Scholar was done using keywords and data was identified and systematically evaluated.

Pregnancy outcome in chronic myeloid leukemia patients on imatinib therapy

INTRODUCTION

Imatinib is a first-line therapy to treat chronic myeloid leukemia (CML) patients.

MATERIALS AND METHODS

We selected 22 CML cases of pregnancies and reported 9 accidental and 13 planned pregnancies that were on imatinib therapy. Willing female patients remaining in complete hematological, cytogenetic and major molecular responses for at least 2 years planned for pregnancy and were advised to stop imatinib for 1 month prior to conception and 3 months after conception (first trimester). Willing male patients stopped therapy 1 month prior to conception of their wives. In unplanned cases, all patients were in exposure to imatinib during conception. Twenty-two pregnancies resulted in seven male children and eight female children. There were three spontaneous abortions and four elective abortions along with one case of hypospadia and another one of mild hydrocephalus.

CONCLUSION

We may suggest that planned pregnancy during therapy may be encouraged but imatinib therapy in unplanned pregnancy can cause spontaneous abortion or congenital anomaly.