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Laganà A, Scalzulli E, Bisegna ML, Carmosino I, Ielo C, Costa A, Torrieri L, Totaro M, Martelli M, Breccia M. Treatment free remission (TFR) after second-generation tyrosine kinase inhibitors (2G-TKIs) treatment in chronic myeloid leukemia (CML): from feasibility to safety. Expert Opin Drug Saf 2024:1-11. [PMID: 38873693 DOI: 10.1080/14740338.2024.2368822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/12/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Chronic myeloid leukemia (CML) prevalence is currently increasing due to the great efficacy of tyrosine kinase inhibitor (TKI) therapy. Discontinuation of treatment in the long-term, owing to avoid off-target side effects or treatment-free remission (TFR), has become an additional treatment goal in CML patients who achieved a deep molecular response (DMR). Second-generation TKIs (2 G-TKIs) have a significantly higher rate of DMR than imatinib. Hence, especially in young patients with a strategy of TFR, 2 G-TKIs are becoming the most frequently used TKIs and may increase TFR attempts in the future. AREAS COVERED In this review, the main findings extrapolated from clinical trials and real-life evidence regarding 2 G-TKIs discontinuation were discussed, through broad research on Medline, Embase, and archives from EHA and ASH congresses. EXPERT OPINION Overall, TFR rate after 2 G-TKIs is ranging from 40% to 60% for selected patients with sustained DMR and it can be considered a safe procedure, that have become, nowadays, a daily practice. However, many crucial aspects regarding treatment choices, timings, as well as predictive factors, patient communication, and optimal strategies need to be better clarified to improve successful TFR rate.
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Affiliation(s)
- Alessandro Laganà
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Laura Bisegna
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia Ielo
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Costa
- Hematology Unit, Department of Medical Sciences and Public Health, Businco Hospital, University of Cagliari, Cagliari, Italy
| | - Lorenzo Torrieri
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Matteo Totaro
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Pichler H, Sedlacek P, Meisel R, Beier R, Faraci M, Kalwak K, Ifversen M, Müller I, Stein J, Vettenranta K, Kropshofer G, Kolenova A, Karlhuber S, Glogova E, Poetschger U, Peters C, Suttorp M, Matthes-Leodolter S, Balduzzi A. Haematopoietic stem cell transplantation after reduced intensity conditioning in children and adolescents with chronic myeloid leukaemia: A prospective multicentre trial of the I-BFM Study Group. Br J Haematol 2024. [PMID: 38803040 DOI: 10.1111/bjh.19535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
This prospective multicentre trial evaluated the safety and the efficacy of a thiotepa/melphalan-based reduced intensity conditioning (RIC) haematopoietic stem cell transplantation (HSCT) in children and adolescents with chronic myeloid leukaemia (CML) in chronic phase (CP). Thirty-two patients were transplanted from matched siblings or matched unrelated donors. In 22 patients, HSCT was performed due to insufficient molecular response or loss of response to first- or second-generation tyrosine kinase inhibitor (TKI), with pretransplant BCR::ABL1 transcripts ranging between 0.001% and 33%. The protocol included a BCR::ABL1-guided intervention with TKI retreatment in the first year and donor lymphocyte infusions (DLI) in the second-year post-transplant. All patients engrafted. The 1-year transplant-related mortality was 3% (confidence interval [CI]: 0%-6%). After a median follow-up of 6.3 years, 5-year overall survival and event-free survival are 97% (CI: 93%-100%) and 91% (CI: 79%-100%) respectively. The current 5-year leukaemia-free survival with BCR::ABL1 <0.01% is 97% (CI: 88%-100%) and the current TKI- and DLI-free survival is 95% (CI: 85%-100%). The incidence of chronic graft-versus-host disease (GvHD) was 32%, being severe in four patients (13%). At last follow-up, 31 patients are GvHD-free and have stopped immunosuppression. RIC HSCT following pretreatment with TKI is feasible and effective in children and adolescents with CP-CML with an excellent disease-free and TKI-free survival.
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Affiliation(s)
- Herbert Pichler
- Department of Paediatric Haematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Petr Sedlacek
- Department of Paediatric Haematology and Oncology, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Rita Beier
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Maura Faraci
- Hematopoietic Stem Cell Transplantation Unit, Department of Hematology and Oncology, IRCCS Institute G. Gaslini, Genoa, Italy
| | - Krzysztof Kalwak
- Clinical Department of Paediatric Bone Marrow Transplantation, Oncology and Haematology, Wrocław Medical University, Wrocław, Poland
| | - Marianne Ifversen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jerry Stein
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Kim Vettenranta
- Paediatric Haemato-Oncology, University of Helsinki, Helsinki, Finland
| | - Gabriele Kropshofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexandra Kolenova
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Children's Haematology and Oncology Clinic, Comenius University in Bratislava, Bratislava, Slovakia
| | - Susanne Karlhuber
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Evgenia Glogova
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Ulrike Poetschger
- Department of Paediatric Haematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Christina Peters
- Department of Paediatric Haematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Meinolf Suttorp
- Paediatric Haemato-Oncology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Susanne Matthes-Leodolter
- Department of Paediatric Haematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Adriana Balduzzi
- Pediatric Transplant Unit, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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3
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Bourne G, Bhatia R, Jamy O. Treatment-Free Remission in Chronic Myeloid Leukemia. J Clin Med 2024; 13:2567. [PMID: 38731096 PMCID: PMC11084227 DOI: 10.3390/jcm13092567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
With the discovery of tyrosine kinase inhibitors (TKIs), overall survival in patients with chronic myeloid leukemia (CML) now approaches that of the general population. While these TKIs have proven to be lifesaving, remaining on them lifelong creates both physical and financial burdens for patients. Recently, multiple trials have begun looking into the efficacy of trialing patients off these TKIs to see if they can sustain treatment-free remission (TFR). TFR eligibility is currently limited to a small population of patients with both robust and sustained responses to TKIs. Currently, for those who attempt a trial of TFR, the average success rates are promising, with anywhere from 38 to 54% of patients experiencing sustained TFR. For those who fail to maintain sustained TFR, safety results to date are reassuring, with almost all patients successfully responding to the re-initiation of TKIs, with death and disease progression being very rare complications. Moving forward, research is being conducted to more accurately risk stratify patients at diagnosis and pair them with optimized upfront treatment regimens aimed at increasing candidacy for the trial of TFR.
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Affiliation(s)
| | | | - Omer Jamy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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4
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Iriyama N, Iwanaga E, Kimura Y, Watanabe N, Ishikawa M, Nakayama H, Sato E, Tabayashi T, Mitsumori T, Takaku T, Nakazato T, Tokuhira M, Fujita H, Ando M, Hatta Y, Kawaguchi T. Changes in chronic myeloid leukemia treatment modalities and outcomes after introduction of second-generation tyrosine kinase inhibitors as first-line therapy: a multi-institutional retrospective study by the CML Cooperative Study Group. Int J Hematol 2024:10.1007/s12185-024-03758-4. [PMID: 38587692 DOI: 10.1007/s12185-024-03758-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/09/2024]
Abstract
This study investigated changes in treatment modalities and outcomes of chronic myeloid leukemia in the chronic phase (CP-CML) after the approval of second-generation tyrosine kinase inhibitors (2G-TKIs) for first-line therapy. Patients were grouped into those who underwent TKI therapy up to December 2010 (imatinib era group, n = 185) and after January 2011 (2G-TKI era group, n = 425). All patients in the imatinib era group were initially treated with imatinib, whereas patients in the 2G-TKI era group were mostly treated with dasatinib (55%) or nilotinib (36%). However, outcomes including progression-free survival, overall survival, and CML-related death (CRD) did not differ significantly between groups. When stratified by risk scores, the prognostic performance of the ELTS score was superior to that of the Sokal score. Even though both scoring systems predicted CRD in the imatinib era, only the ELTS score predicted CRD in the 2G-TKI era. Notably, the outcome of patients classified as high-risk by ELTS score was more favorable in the 2G-TKI era group than in the imatinib era group. Thus, expanding treatment options may have improved patient outcomes in CP-CML, particularly in patients classified as high-risk by ELTS score.
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Affiliation(s)
- Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Eisaku Iwanaga
- Department of Hematology, Rheumatology and Infectious Diseases, Kumamoto University Hospital, Kumamoto, Japan
| | - Yuta Kimura
- Department of Hematology, Japan Community Health Care Organization, Saitama Medical Center, Saitama, Japan
| | - Naoki Watanabe
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Maho Ishikawa
- Department of Hemato-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hitomi Nakayama
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Eriko Sato
- Department of Hematology, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Takayuki Tabayashi
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toru Mitsumori
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Tomoiku Takaku
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Michihide Tokuhira
- Department of Hematology, Japan Community Health Care Organization, Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Miki Ando
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshihiro Hatta
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tatsuya Kawaguchi
- Department of Hematology, Rheumatology and Infectious Diseases, Kumamoto University Hospital, Kumamoto, Japan
- Department of Medical Technology, Kumamoto Health Science University, Kumamoto, Japan
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5
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Ureshino H, Kamachi K, Kimura S. Second Treatment-Free Remission Attempt in Patients with Chronic Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e138-e141. [PMID: 38195325 DOI: 10.1016/j.clml.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
Long-term survival outcomes of patients with chronic myeloid leukemia in the chronic phase are now similar to those of the general population, following the introduction of ABL1 tyrosine kinase inhibitors (TKIs). Approximately 40% to 80% of patients with chronic myeloid leukemia successfully achieved treatment-free remission after the first attempt of TKI discontinuation (TFR1), after achieving a durable deep molecular response. However, the possibility of achieving treatment-free remission after a second attempt of TKI discontinuation (TFR2) remains unclear. Therefore, we reviewed current TFR2 studies to clarify the feasibility of achieving TFR2. We identified 5 TFR2 clinical trials and 2 real-world reports. TFR2 attempt may be feasible after retreatment with imatinib, nilotinib, or dasatinib. Patients who have achieved MR4.0 or deeper durable molecular remission are eligible to enter the TFR2 phase. Imatinib is well tolerated and can be administered for consolidative treatment before the TFR2 attempt, whereas drug-related adverse effects of nilotinib or dasatinib affect their tolerability and might lead to discontinuation. Late onset relapse (> 1 year or > 2 year) was often reported, thus careful monitoring is needed.
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Affiliation(s)
- Hiroshi Ureshino
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.
| | - Kazuharu Kamachi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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Flygt H, Söderlund S, Richter J, Saussele S, Koskenvesa P, Stenke L, Mustjoki S, Dimitrijevic A, Stentoft J, Majeed W, Roy L, Wolf D, Dreimane A, Gjertsen BT, Gedde-Dahl T, Ahlstrand E, Markevärn B, Hjorth-Hansen H, Janssen J, Olsson-Strömberg U. Treatment-free remission after a second TKI discontinuation attempt in patients with Chronic Myeloid Leukemia re-treated with dasatinib - interim results from the DAstop2 trial. Leukemia 2024; 38:781-787. [PMID: 38278960 PMCID: PMC10997502 DOI: 10.1038/s41375-024-02145-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/25/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024]
Abstract
Tyrosine kinase inhibitor (TKI) discontinuation in chronic myeloid leukemia (CML) has become part of routine care for patients with a sustained deep molecular response (DMR). Approximately 50% experience a molecular relapse upon TKI cessation. Most of them quickly regain DMR upon TKI resumption. Whether these patients can achieve a second treatment-free remission (TFR) remains unclear. DAstop2 (ClinicalTrials.gov ID: NCT03573596) is a prospective study including patients with a failed first TFR attempt re-treated with any TKI for ≥ one year. Upon entering the study, patients received the TKI dasatinib for additional two years. Patients with sustained DMR for ≥1 year qualified for a second TKI stop. Ninety-four patients were included between Oct 2017-Dec 2021. At the time of data analysis, 62 patients had attempted a 2nd stop. After a median follow-up of 27 months from 2nd stop, TFR rates were 61, 56 and 46% at 6, 12 and 24 months respectively. No progression to advanced stage disease was seen and 87% had re-achieved MR4 within a median of 3 months from TKI re-initiation. In summary, we show that a 2nd TFR attempt after dasatinib treatment is safe, feasible and TFR rates seem in the range of those reported in trials of a first TKI stop.
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Affiliation(s)
- Hjalmar Flygt
- Department of Medical Science and Division of Hematology, Uppsala University Hospital, Uppsala, Sweden.
| | - Stina Söderlund
- Department of Medical Science and Division of Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Johan Richter
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Susanne Saussele
- Medical Clinic, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Perttu Koskenvesa
- Department of Hematology, Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Leif Stenke
- Department of Hematology, Karolinska University Hospital and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Satu Mustjoki
- Department of Hematology, Hematology Research Unit Helsinki and Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
- ICAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland
| | | | - Jesper Stentoft
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Waleed Majeed
- Department of Hemato-Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Lydia Roy
- French CML group Fi-LMC, Centre Léon Bérard, Lyon, Hôpital Universitaire Henri Mondor, AP-HP, Service d'hématologie Clinique & Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Dominik Wolf
- Department of Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Tyrolean Cancer Research Institute (TKFI), Medical University Innsbruck, Innsbruck, Austria
- Medical Clinic 3, Universitätsklinikum, Bonn, Germany
| | - Arta Dreimane
- Department of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Bjørn Tore Gjertsen
- Department of Internal Medicine, Hematology Section, Haukeland University Hospital, Bergen, Norway
| | - Tobias Gedde-Dahl
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Ahlstrand
- Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Berit Markevärn
- Department of Hematology, Umeå University Hospital, Umeå, Sweden
| | | | - Jeroen Janssen
- Department of Hematology, Radboud University medical center, Nijmegen, The Netherlands
| | - Ulla Olsson-Strömberg
- Department of Medical Science and Division of Hematology, Uppsala University Hospital, Uppsala, Sweden
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Uchida Y, Koyama D, Manabe K, Suzuki K, Asano N, Endo M, Fukatsu M, Sano T, Hayashi K, Takano M, Takahashi H, Kimura S, Ikezoe T. High Efficacy and Safety of Asciminib in a Chronic Myeloid Leukemia Patient with Chronic Kidney Disease Following Renal Transplantation. Intern Med 2024; 63:717-720. [PMID: 37407456 PMCID: PMC10982009 DOI: 10.2169/internalmedicine.2179-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/29/2023] [Indexed: 07/07/2023] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm driven by the BCR::ABL1 tyrosine kinase. Tyrosine kinase inhibitors (TKIs) have been established as standard therapies for CML. However, some CML patients experience TKI intolerance. Asciminib was approved for CML patients either intolerant or refractory to TKI therapy. We herein report a 63-year-old CML patient who underwent renal transplantation and exhibited TKI intolerance. He was switched to asciminib, which achieved a deep molecular response without exacerbation of the renal function. Our experience revealed that asciminib is effective and safe for CML patients complicated with chronic kidney disease.
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Affiliation(s)
- Yasuhiro Uchida
- Department of Hematology, Fukushima Medical University, Japan
| | - Daisuke Koyama
- Department of Hematology, Fukushima Medical University, Japan
| | - Kazuya Manabe
- Department of Hematology, Fukushima Medical University, Japan
| | - Kengo Suzuki
- Department of Hematology, Fukushima Medical University, Japan
| | - Naomi Asano
- Department of Hematology, Fukushima Medical University, Japan
| | - Mamiko Endo
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Takahiro Sano
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Motoki Takano
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Satoshi Kimura
- Department of Hematology, Fukushima Medical University, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Japan
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8
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Zhang Z, Zhou X, Zhou X, Cheng Z, Hu Y. Exploration of treatment-free remission in CML, based on molecular monitoring. Cancer Med 2023; 13:e6849. [PMID: 38133525 PMCID: PMC10807643 DOI: 10.1002/cam4.6849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Typical chronic myelogenous leukemia (CML) is a myeloproliferative neoplasm caused by t(9; 22)(q34; q11) translocation. This chromosomal translocation forms the BCR::ABL1 fusion gene. The tyrosine kinase encoded by the BCR::ABL1 is considered to be the main pathogenic diver. BCR::ABL1 is not only a therapeutic target, but also a monitoring target. Monitoring of BCR::ABL1 reveals the progression of the disease and guides the next treatment. Now for CML, the target of treatment has been focused on treatment-free remission (TFR). METHODS We conducted a literature review of current developments of treatment-free remission and molecular monitoring methods. RESULTS More effective and sensitive CML monitoring methods such as digital droplet PCR (ddPCR) and next generation sequencing (NGS) have further studied the measurable residual disease (MRD) and clonal heterogeneity, which provides strong support for the exploration of TFR. We discussed some of the factors that may be related to TFR outcomes at the molecular level, along with some monitoring strategies. CONCLUSION Currently, predictive indicators for treatment-free remission outcomes and recurrence are lacking in clinical practice. In future, treatment-free remission research should focus on combining the clinical indicators with molecular monitoring and biological markers to personalize patient conditions and guide clinicians to develop individualized treatment plans, so that more patients with CML can achieve safer and stabler treatment-free remission.
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Affiliation(s)
| | | | - Xin Zhou
- Wuhan Union HospitalWuhanHubeiChina
| | | | - Yu Hu
- Wuhan Union HospitalWuhanHubeiChina
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9
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Allegra S, Dondi E, Chiara F, De Francia S. Pharmacokinetics of Four Tyrosine Kinase Inhibitors in Adult and Paediatric Chronic Myeloid Leukaemia Patients. Biomedicines 2023; 11:2478. [PMID: 37760918 PMCID: PMC10525795 DOI: 10.3390/biomedicines11092478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Tyrosine kinase inhibitors work by blocking the tyrosine kinases responsible for the dysregulation of intracellular signalling pathways in tumour cells. This study looked at the impact of age and sex on the levels of imatinib, dasatinib, nilotinib, and ponatinib in plasma and cerebrospinal fluid samples of patients with chronic myeloid leukaemia. Imatinib and dasatinib were used to treat the majority of the enrolled patients, and most of them were paediatrics. A total of 82.4% of the patients were men; however, sex-related differences in the drugs' pharmacokinetics were not found. Age and imatinib plasma concentration were found to be inversely correlated. The dasatinib concentrations in plasma were found to be substantially lower than those found in cerebrospinal fluid, particularly in paediatrics. Analysing the obtained data, we can state that therapeutic drug monitoring is a useful method for adjusting a patient's treatment schedule that depends on drug concentrations in biological fluids. The use of therapeutic drug monitoring in conjunction with tyrosine kinase inhibitors for the treatment of chronic myeloid leukaemia is supported by a number of sources of evidence. As a result, as the research develops, the tyrosine kinase inhibitor therapeutic drug monitoring classification needs to be refined in terms of factors like sex and age.
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Yoo JW, Jo S, Ahn MB, Kim S, Lee JW, Kim M, Cho B, Chung NG. Front-Line Tyrosine Kinase Inhibitors in Pediatric Chronic Myeloid Leukemia: A Study on Efficacy and Safety. Cancers (Basel) 2023; 15:3862. [PMID: 37568679 PMCID: PMC10416896 DOI: 10.3390/cancers15153862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
We conducted a retrospective study on 51 pediatric patients with newly diagnosed chronic myeloid leukemia chronic phase or accelerated phase. The patients were classified into the IMA group (N = 33), treated with imatinib, and the DSA group (N = 18), treated with dasatinib, as front-line tyrosine kinase inhibitors (TKIs). At 12 months, the rates of complete cytogenetic response were similar between the IMA group (92.3%) and DSA group (100%) (p = 0.305). However, the rate of early molecular response was higher in the DSA group than in the IMA group (100.0% vs. 80.0%, p = 0.043). By 12 and 24 months, the DSA group showed faster and higher cumulative rates of both major (DSA group: 72.2% and 100%, respectively; IMA group: 41.2% and 68.7%, respectively; p = 0.002) and deep molecular responses (DSA group: 26.0% and 43.6%, respectively; IMA group: 13.8% and 17.5%, respectively; p = 0.004). Both TKIs were well tolerated. Although the height standard deviation scores decreased in both groups, the height decline was greater in the DSA group between one and two years from the start of TKI therapy. In this study, dasatinib achieved faster and higher molecular responses with an acceptable safety profile. Further follow-up is necessary to assess the long-term outcomes of TKI treatment in children.
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Affiliation(s)
- Jae Won Yoo
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Suejung Jo
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Moon Bae Ahn
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Seongkoo Kim
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Jae Wook Lee
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Myungshin Kim
- Catholic Genetic Laboratory Center, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Bin Cho
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
| | - Nack-Gyun Chung
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.W.Y.); (S.J.); (S.K.); (J.W.L.); (B.C.)
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11
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Sweet KL, Cortes JE, Apperley JF, Mann M, Mauro MJ, Oehler VG, Ruiz C, Schiffer CA, Ehrlich LA, Pamuk GE, Wynne J, Mehta GU, de Claro RA, Theoret MR, Smith BD, Norsworthy KJ. Project Confirm: Accelerated Drug Approvals for Chronic Myeloid Leukemia. Clin Cancer Res 2023; 29:2179-2183. [PMID: 36547666 PMCID: PMC10272032 DOI: 10.1158/1078-0432.ccr-22-2628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/15/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022]
Abstract
The FDA has an accelerated approval program for drugs that have been identified as promising treatments for serious conditions when the available data suggest that the benefits outweigh the foreseeable risks. All of the currently available treatment options for chronic myeloid leukemia (CML) initially went through the accelerated approval program. Here, a group of academic CML experts, patient panelists, and members from the FDA convened to discuss the utility of the accelerated approval program as it pertains to CML, and the utility of this program in future drug development in this disease. The results of that discussion are summarized here.
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Affiliation(s)
| | | | | | | | - Michael J. Mauro
- Myeloproliferative Neoplasms Program, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Vivian G. Oehler
- Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA
| | | | - Charles A. Schiffer
- Department of Hematology-Oncology, Karmanos Cancer Center at Wayne State University, Detroit, MI
| | - Lori A. Ehrlich
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
| | - Gulsum E. Pamuk
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
| | - Joseph Wynne
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
| | - Gautam U. Mehta
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
| | - R. Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
| | - Marc R. Theoret
- Oncology Center of Excellence, U.S. Food and Drug Administration, Washington, DC
| | - B. Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Kelly J. Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Washington, DC
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12
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Yoshida C, Yamaguchi H, Doki N, Murai K, Iino M, Hatta Y, Onizuka M, Yokose N, Fujimaki K, Hagihara M, Oshikawa G, Murayama K, Kumagai T, Kimura S, Najima Y, Iriyama N, Tsutsumi I, Oba K, Kojima H, Sakamaki H, Inokuchi K. Importance of TKI treatment duration in treatment-free remission of chronic myeloid leukemia: results of the D-FREE study. Int J Hematol 2023; 117:694-705. [PMID: 36739328 PMCID: PMC10121524 DOI: 10.1007/s12185-023-03549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
Treatment-free remission (TFR) is a new goal for patients with chronic myeloid leukemia in chronic phase (CML-CP) with a sustained deep molecular response (DMR) to treatment with tyrosine kinase inhibitors (TKIs). However, optimal conditions for successful TFR in patients treated with second-generation (2G)-TKIs are not fully defined. In this D-FREE study, treatment discontinuation was attempted in newly diagnosed CML-CP patients treated with the 2G-TKI dasatinib who achieved BCR-ABL1 levels of ≤ 0.0032% (MR4.5) on the international scale (BCR-ABL1IS) and maintained these levels for exactly 1 year. Of the 173 patients who received dasatinib induction therapy for up to 2 years, 123 completed and 60 (48.8%) reached MR 4.5. Among the first 21 patients who maintained MR4.5 for 1 year and discontinued dasatinib, 17 experienced molecular relapse defined as loss of major molecular response (BCR-ABL1IS > 0.1%) confirmed once, or loss of MR4 (BCR-ABL1IS > 0.01%) confirmed on 2 consecutive assessments. The estimated molecular relapse-free survival rate was 16.7% at 12 months. This study was prematurely terminated according to the protocol's safety monitoring criteria. The conclusion was that sustained DMR for just 1 year is insufficient for TFR in CML-CP patients receiving dasatinib for less than a total of 3 years of treatment.
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Affiliation(s)
- Chikashi Yoshida
- Department of Hematology, National Hospital Organization Mito Medical Center, 280 Sakuranosato, Ibarakimachi, Higashiibarakigun, Ibaraki, 311-3193, Japan.
| | | | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazunori Murai
- Department of Hematology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Masaki Iino
- Department of Medical Oncology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Yoshihiro Hatta
- Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Norio Yokose
- Department of Hematology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | | | - Masao Hagihara
- Department of Hematology, EIJU General Hospital, Taito-Ku, Japan
| | - Gaku Oshikawa
- Japanese Red Cross Musashino Hospital, Musashino, Japan
| | - Kayoko Murayama
- Division of Hematology, Gunma Prefectural Cancer Center, Ohta, Japan
| | - Takashi Kumagai
- Department of Hematology, Ome Municipal General Hospital, Ome-Shi, Tokyo, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriyoshi Iriyama
- Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Ikuyo Tsutsumi
- Department of Hematology, National Hospital Organization Mito Medical Center, 280 Sakuranosato, Ibarakimachi, Higashiibarakigun, Ibaraki, 311-3193, Japan
| | - Koji Oba
- Department of Biostatistics, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Kojima
- Ibaraki Clinical Education and Training Center, University of Tsukuba Hospital, Kasama, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Koiti Inokuchi
- Department of Hematology, Nippon Medical School, Tokyo, Japan
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13
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Cheng F, Li Q, Cui Z, Hong M, Li W, Zhang Y. Dose optimization strategy of the tyrosine kinase inhibitors imatinib, dasatinib, and nilotinib for chronic myeloid leukemia: From clinical trials to real-life settings. Front Oncol 2023; 13:1146108. [PMID: 37091188 PMCID: PMC10113500 DOI: 10.3389/fonc.2023.1146108] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/23/2023] [Indexed: 04/08/2023] Open
Abstract
With the advent of tyrosine kinase inhibitors (TKIs), the treatment prospects of chronic myeloid leukemia (CML) have changed markedly. This innovation can lengthen the long-term survival of patients suffering from CML. However, long-term exposure to TKIs is accompanied by various adverse events (AEs). The latter affect the quality of life and compliance of patients with CML, and may lead to serious disease progression (and even death). Recently, increasing numbers of patients with CML have begun to pursue a dose optimization strategy. Dose optimization may be considered at all stages of the entire treatment, which includes dose reduction and discontinuation of TKIs therapy. In general, reduction of the TKI dose is considered to be an important measure to reduce AEs and improve quality of life on the premise of maintaining molecular responses. Furthermore, discontinuation of TKIs therapy has been demonstrated to be feasible and safe for about half of patients with a stable optimal response and a longer duration of TKI treatment. This review focuses mainly on the latest research of dose optimization of imatinib, dasatinib, and nilotinib in CML clinical trials and real-life settings. We consider dose reduction in newly diagnosed patients, or in optimal response, or for improving AEs, either as a prelude to treatment-free remission (TFR) or as maintenance therapy in those patients unable to discontinue TKIs therapy. In addition, we also focus on discontinuation of TKIs therapy and second attempts to achieve TFR.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Zheng Cui
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Mei Hong
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yu Zhang, ; Weiming Li,
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
- *Correspondence: Yu Zhang, ; Weiming Li,
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14
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Chen Y, Zhao H, Guo J, Zou J, He W, Han D, Cheng F, Zhang Y, Li W. Successful treatment discontinuation in CML patients with full-dose and low-dose TKI: Results from real-world practice. Front Pharmacol 2023; 14:1101743. [PMID: 36755944 PMCID: PMC9899816 DOI: 10.3389/fphar.2023.1101743] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
Background: In clinical studies, some patients who achieve deep molecular response (DMR) can successfully discontinue tyrosine kinase inhibitor (TKI). TKI dose reduction is also an important aspect of alleviating adverse effects and improving quality of life. This study aimed to explore the outcome after drug withdrawal in Chinese CML patients. Methods: We conducted a retrospective analysis of the outcome of 190 patients who stopped TKI. 27 patients experienced dose reduction before TKI discontinuation. The median duration of TKI treatment and MR4 before discontinuation was 82 months and 61 months. Results: With median follow-up after stopping TKI treatment of 17 months, the estimated TFR (Treatment Free Remission) were 76.9% (95%CI, 70.2%-82.4%), 68.8% (95%CI, 61.3%-75.2%), and 65.5% (95%CI, 57.4%-72.5%) at 6, 12 and 24 months. For full-dose and low-dose TKI groups, the TFR at 24 months was 66.7% and 55.8% (p = 0.320, log-rank). Most patients (56/57) quickly achieved MMR after restarting TKI treatment. Multivariable analysis showed that patients with TKI resistance had a higher risk of molecular relapse than patients without TKI resistance (p < 0.001). Conclusion: TFR rates were not impaired in patients experiencing dose reduction before TKI discontinuation compared to patients with full-dose TKI. Our data on Chinese population may provide a basis for the safety and feasibility of TKI discontinuation, including discontinuation after dose reduction, in clinical practice.
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Affiliation(s)
- Yilin Chen
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huifang Zhao
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jingming Guo
- Department of Hematology, Yichang Central People’s Hospital & First Clinical Medical College of China Three Gorges University, Yichang, Hubei, China
| | - Jing Zou
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenjuan He
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Danlei Han
- Department of Hematology, Yichang Central People’s Hospital & First Clinical Medical College of China Three Gorges University, Yichang, Hubei, China
| | - Fanjun Cheng
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China,*Correspondence: Yanli Zhang, ; Weiming Li, ; Fanjun Cheng,
| | - Yanli Zhang
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China,*Correspondence: Yanli Zhang, ; Weiming Li, ; Fanjun Cheng,
| | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China,*Correspondence: Yanli Zhang, ; Weiming Li, ; Fanjun Cheng,
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15
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Rinaldi I, Winston K. Chronic Myeloid Leukemia, from Pathophysiology to Treatment-Free Remission: A Narrative Literature Review. J Blood Med 2023; 14:261-277. [PMID: 37051025 PMCID: PMC10084831 DOI: 10.2147/jbm.s382090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 02/06/2023] [Indexed: 04/14/2023] Open
Abstract
Chronic myeloid leukemia (CML) is one of the most common leukemias occurring in the adult population. The course of CML is divided into three phases: the chronic phase, the acceleration phase, and the blast phase. Pathophysiology of CML revolves around Philadelphia chromosome that constitutively activate tyrosine kinase through BCR-ABL1 oncoprotein. In the era of tyrosine kinase inhibitors (TKIs), CML patients now have a similar life expectancy to people without CML, and it is now very rare for CML patients to progress to the blast phase. Only a small proportion of CML patients have resistance to TKI, caused by BCR-ABL1 point mutations. CML patients with TKI resistance should be treated with second or third generation TKI, depending on the BCR-ABL1 mutation. Recently, many studies have shown that it is possible for CML patients who achieve a long-term deep molecular response to stop TKIs treatment and maintain remission. This review aimed to provide an overview of CML, including its pathophysiology, clinical manifestations, the role of stem cells, CML treatments, and treatment-free remission.
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Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Correspondence: Ikhwan Rinaldi, Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia, Email
| | - Kevin Winston
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Hospital Medicine, Bhakti Medicare Hospital, Sukabumi, Indonesia
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16
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Narlı Özdemir Z, Kılıçaslan NA, Yılmaz M, Eşkazan AE. Guidelines for the treatment of chronic myeloid leukemia from the NCCN and ELN: differences and similarities. Int J Hematol 2023; 117:3-15. [PMID: 36064839 DOI: 10.1007/s12185-022-03446-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 01/07/2023]
Abstract
Patients diagnosed with chronic myeloid leukemia (CML) in chronic phase can now have a life expectancy comparable to that of the general population thanks to the use of tyrosine kinase inhibitor (TKI) therapies. Although most patients with CML require lifelong TKI therapy, it is possible for some patients to achieve treatment-free remission. These spectacular results have been made possible by the development of superior treatment modalities as well as clinicians' efforts in strictly adhering to clinical guidelines such as the National Comprehensive Cancer Network (NCCN) and European Leukemia Network (ELN). CML treatment recommendations reported in these guidelines are the result of years of selecting and incorporating the most reliable evidence. In this review, we provide a synopsis of the differences and similarities that exist between the NCCN and ELN guidelines.
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Affiliation(s)
- Zehra Narlı Özdemir
- Department of Hematology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | | | - Musa Yılmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Fatih, Istanbul, Turkey.
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17
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Roy L, Chomel JC, Guilhot J, Guerci-Bresler A, Escoffre-Barbe M, Giraudier S, Charbonnier A, Dubruille V, Huguet F, Johnson-Ansah H, Lenain P, Ame S, Etienne G, Nicolini FE, Rea D, Cony-Makhoul P, Courby S, Ianotto JC, Legros L, Machet A, Coiteux V, Hermet E, Cayssials E, Bouchet S, Mahon FX, Rousselot P, Guilhot F. Dasatinib plus Peg-Interferon alpha 2b combination in newly diagnosed chronic phase chronic myeloid leukaemia: Results of a multicenter phase 2 study (DASA-PegIFN study). Br J Haematol 2023; 200:175-186. [PMID: 36214090 DOI: 10.1111/bjh.18486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/04/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Superior rates of deep molecular response (DMR) have been reported with the combination of tyrosine kinase inhibitors and pegylated-interferon-alpha (Peg-IFN) in patients with newly diagnosed chronic phase-chronic myeloid leukaemia (CP-CML). In this setting, this study investigated the efficacy and safety of dasatinib combined to Peg-IFN-α2b (Dasa-PegIFN, NCT01872442). A total of 79 patients (age ≤65 years) started dasatinib; 61 were eligible for Peg-IFNα-2b add-on therapy at month 3 for a maximum 21-months duration. Dasatinib was continued thereafter. The primary endpoint was the cumulative rate of molecular response 4.5 log (MR4.5 ) by 12 months. The results are reported for the 5-year duration of the study. Grade 3 neutropenia was frequent with the combination but did not induce severe infection (one of grade 3). Other adverse events were generally low grade (4% of grade 3-4) and expected. Seventy-nine per cent and 61% of patients continued the Peg-IFN until months 12 and 24, respectively. Overall, at these time points, MR4.5 rates were 25% and 38%, respectively. Thereafter, 32% and 46% of patients achieved a sustained (≥2 years) MR4.5 or MR4 , respectively. This work established the feasibility and high rates of achievement of early and sustained DMR (a prerequisite for treatment-free-remission) with dasatinib and Peg-IFNα-2b combination as initial therapy.
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Affiliation(s)
- Lydia Roy
- Hôpital Universitaire Henri Mondor, APHP, Faculté de Santé, UPEC, Service d'Hématologie Clinique, Créteil, France
| | | | | | | | | | - Stéphane Giraudier
- Hôpital Saint-Louis, APHP et INSERM Université de Paris, Service de biologie cellulaire, Paris, France
| | - Aude Charbonnier
- Institut Paoli-Calmettes, Service d'Hématologie Clinique, Marseille, France
| | | | - Françoise Huguet
- Service d'Hématologie Clinique, CHU Toulouse, I.U.C.T.O, Toulouse, France
| | | | - Pascal Lenain
- Centre Henri Becquerel, Service d'Hématologie Clinique, Rouen, France
| | - Shanti Ame
- CHU Strasbourg, Service d'Hématologie Clinique, Strasbourg, France
| | - Gabriel Etienne
- Institut Bergonié, Service d'Hématologie Clinique, Bordeaux, France
| | - Franck E Nicolini
- Centre Léon Bérard, Service d'Hématologie Clinique & INSERM U1052 CRC, Lyon, France
| | - Delphine Rea
- Hôpital St Louis, APHP, Service d'Hématologie Clinique, Paris, France
| | | | - Stéphane Courby
- CHU Grenoble Service d'Hématologie Clinique, Grenoble, France
| | | | - Laurence Legros
- Hôpital Paul Brousse, AP-HP, Service d'Hématologie Clinique, INSERM UMRS-MD1197, Villejuif, France
| | - Antoine Machet
- Hôpital Bretonneau, CHRU Tours Service d'Hématologie Clinique, Tours, France
| | - Valérie Coiteux
- Hôpital Claude Huriez, CHRU Lille Service d'Hématologie Clinique, Lille, France
| | - Eric Hermet
- CHU d'Estaing, Clermont-Ferrand, Service d'Hématologie Clinique, Clermont-Ferrand, France
| | - Emilie Cayssials
- INSERM CIC 1402, CHU Poitiers, Poitiers, France.,CHU de Poitiers, Service d'Hématologie Clinique, Poitiers, France
| | - Stéphane Bouchet
- Hôpital Pellegrin, CHU Bordeaux, Laboratoire de pharmacologie, Bordeaux, France
| | | | - Philippe Rousselot
- Centre Hospitalier de Versailles, Université Paris Saclay UMR 1184, Service d'Hématologie Clinique, Le Chesnay, France
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- French CML group (Fi-LMC), Centre Léon Bérard, Lyon, France
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18
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Ureshino H, Kamachi K, Sano H, Okamoto S, Itamura H, Yoshimura M, Katsuya H, Ando T, Kimura S. Higher neutrophil counts are associated with successful tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia. Hematology 2022; 27:1171-1175. [DOI: 10.1080/16078454.2022.2135857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kazuharu Kamachi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Haruhiko Sano
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Sho Okamoto
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hidekazu Itamura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Mariko Yoshimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Toshihiko Ando
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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Digital PCR as a New Method for Minimal Residual Disease Monitoring and Treatment Free Remission Management in Chronic Myeloid Leukemia Patients: Is It Reliable? HEMATO 2022. [DOI: 10.3390/hemato4010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The effective and sensitive monitoring of Minimal Residual Disease or Measurable Residual Disease (MRD) is a very important aspect in the management of patients affected by hematologic malignancies. The recent availability of new technologies has opened to the improvement of MRD monitoring. It is particularly relevant in patients affected by Chronic Myeloid Leukemia (CML). MRD monitoring is key in the management of CML patients thanks to the efficacy of TKIs therapy. Moreover, the policies of TKIs discontinuation aimed at treatment free remission are strongly based on the good selection of patients eligible for stopping TKIs therapy. The recently described application of digital PCR in CML patients monitoring seems to improve the accuracy and precision in the identification of optimal responders. The present review reports an overview on the application of digital PCR in the monitoring of MRD in CML and its impact on TKIs discontinuation trials and, consequently, on TFR success.
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20
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Genetic Alterations and Deregulation of Hippo Pathway as a Pathogenetic Mechanism in Bone and Soft Tissue Sarcoma. Cancers (Basel) 2022; 14:cancers14246211. [PMID: 36551696 PMCID: PMC9776600 DOI: 10.3390/cancers14246211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
The Hippo pathway is an evolutionarily conserved modulator of developmental biology with a key role in tissue and organ size regulation under homeostatic conditions. Like other signaling pathways with a significant role in embryonic development, the deregulation of Hippo signaling contributes to oncogenesis. Central to the Hippo pathway is a conserved cascade of adaptor proteins and inhibitory kinases that converge and regulate the activity of the oncoproteins YAP and TAZ, the final transducers of the pathway. Elevated levels and aberrant activation of YAP and TAZ have been described in many cancers. Though most of the studies describe their pervasive activation in epithelial neoplasms, there is increasing evidence pointing out its relevance in mesenchymal malignancies as well. Interestingly, somatic or germline mutations in genes of the Hippo pathway are scarce compared to other signaling pathways that are frequently disrupted in cancer. However, in the case of sarcomas, several examples of genetic alteration of Hippo members, including gene fusions, have been described during the last few years. Here, we review the current knowledge of Hippo pathway implication in sarcoma, describing mechanistic hints recently reported in specific histological entities and how these alterations represent an opportunity for targeted therapy in this heterogeneous group of neoplasm.
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21
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Luo J, Du X, Lou J, Wu J, Ma L, Huang J, Wang L, Tu C, Liu Z, Chen L, Tan Y, Luo D, Liang H, Yin C, Cao R, Zhou X, Liu Q, Liu X, Xu N. De-escalation or discontinuation of tyrosine kinase inhibitor in patients with chronic myeloid leukemia: A multicentral, open-label, prospective trial in China. EJHAEM 2022; 3:1220-1230. [PMID: 36467815 PMCID: PMC9713036 DOI: 10.1002/jha2.550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 06/17/2023]
Abstract
Background: Long-term treatment-free remission (TFR) represents a new goal for chronic myeloid leukemia (CML). Optimizing dose of tyrosine kinase inhibitors (TKIs) in the CML treatment maybe a new challenge to maintain effective and improving patients' quality of life. We hypothesized that administration of low-dose TKIs does not compromise major molecular response (MMR) in patients with CML who have a deep molecular response (DMR). Methods: We did an open-label, randomized trial at eight hospitals in China. Eligible CML-CP patients (aged 18-70 years) had shown continuous response to TKI more than 5 years and maintained MR4.5 (BCR-ABLIS ≤ 0.0032%) in recent 18 months. Patients were randomly assigned (1:1) to the TKI de-escalation group or the discontinuation group. Randomization was done with permuted blocks (block size four) and implemented through an interactive web-based randomization system. Recurrence was defined as the single sample with real time Quantitative PCR (RT-qPCR) measurement greater than 0.1% (MMR). The primary endpoint was 12-month MMR rate in patients who received de-escalation or discontinuation of TKIs. This study was registered at ClinicalTrials.gov (NCT04143087). Results: Around 125 patients were enrolled between October 23, 2019 and October 31, 2020, 62 patients received dose de-escalation of TKIs, while 63 patients in the discontinuation group. In the de-escalation group, molecular recurrence-free survival at 12 months was 88.32% (95% CI 79%-98%), whereas molecular recurrence-free survival in the discontinuation group at 12 months was 59.98% (95% CI 47-73). No progressions occurred at the data cut-off date. All 29 recurrence cases restart TKI treatment returned to MMR. Cytolytic NK cells as a proportion of lymphocyte cells were significantly increased from baseline after 6 months whether in the de-escalation or TKIs cessation group (P = 0.048, 0.001, respectively); compared with the relapsing patients, Tregs proportion was decreased (P = 0.003), and higher proportion of NK cells were found in non-relapsing patients whether in TKI de-escalation or discontinuation group (P = 0.011, 0.007, respectively). We also found that the de-escalation group showed better disease-specific HRQOL in regards to its impact on emotional functioning, fatigue, pain, and financial difficulties. Conclusion: With 88.32% MMR in 12-months follow-up after de-escalation TKIs' treatment, dose-halving could become a new treatment paradigm for CML patients who with DMR under continuing maintenance therapy with TKIs.
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Affiliation(s)
- Jie Luo
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Xin Du
- Department of Hematology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen UniversityShenzhen University School of MedicineShenzhenChina
| | - Jin Lou
- Department of Hematology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen UniversityShenzhen University School of MedicineShenzhenChina
| | - Jianwei Wu
- Department of HematologyJinan University Affiliated Jiangmen Hospital of Traditional Chinese MedicineJiangmenGuangdongChina
| | - Liping Ma
- Department of Hematology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Jixian Huang
- Department of Hematology, Yuebei People's HospitalShantou UniversityShaoguanGuangdongChina
| | - Liangtuo Wang
- Department of HematologyPeople's hospital of Yang JiangYang JiangGuangdongChina
| | - Chuanqing Tu
- Department of Hematology, Bao' an District People HospitalThe Second Affiliated Hospital of Shenzhen UniversityShenzhenChina
| | - Zelin Liu
- Department of HematologyHuazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital)ShenzhenChina
| | - Liya Chen
- Department of Medical Quality ManagementNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yaxian Tan
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Dongmei Luo
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Hanyin Liang
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Changxin Yin
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Rui Cao
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Xuan Zhou
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Qifa Liu
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Xiaoli Liu
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Na Xu
- Department of HematologyNanfang HospitalSouthern Medical UniversityGuangzhouChina
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22
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Yoshifuji K, Sasaki K. Adverse events and dose modifications of tyrosine kinase inhibitors in chronic myelogenous leukemia. Front Oncol 2022; 12:1021662. [PMID: 36276124 PMCID: PMC9583346 DOI: 10.3389/fonc.2022.1021662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022] Open
Abstract
The prognosis of chronic myelogenous leukemia (CML-CP) in chronic phase has improved dramatically since the introduction of imatinib. In addition to imatinib, second- and third-generation tyrosine kinase inhibitors (TKIs) and a novel allosteric inhibitor, asciminib, are now available. During long-term TKI therapy, the optimal selection of TKI therapy for individual patients requires the understanding of specific patterns of toxicity profile to minimize chronic toxicity and the risk of adverse events, including pulmonary arterial hypertension, pleural effusion, and cardiovascular events. Given the high efficacy of TKI therapy, dose modifications of TKI therapy reduce the risk of toxicities and improves quality of life during therapy. In this review article, we summarize the characteristics and adverse event profile of each TKI and dose modifications in patients with CML-CP and discuss future perspectives in the treatment of CML-CP.
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Affiliation(s)
- Kota Yoshifuji
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Koji Sasaki,
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Ureshino H, Kamachi K, Shindo T, Kimura S. Favorable HLA Polymorphisms are Associated with Lower Molecular Relapse after Tyrosine Kinase Discontinuation in Patients with Chronic Myeloid Leukemia. Indian J Hematol Blood Transfus 2022; 38:760-761. [PMID: 36258730 PMCID: PMC9569246 DOI: 10.1007/s12288-022-01538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Kazuharu Kamachi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Takero Shindo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501 Japan
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Tyrosine Kinase Inhibitors Do Not Promote a Decrease in SARS-CoV-2 Anti-Spike IgG after BNT162b2 Vaccination in Chronic Myeloid Leukemia: A Prospective Observational Study. Vaccines (Basel) 2022; 10:vaccines10091404. [PMID: 36146482 PMCID: PMC9501552 DOI: 10.3390/vaccines10091404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
We performed a prospective observational study of chronic myeloid leukemia (CML) patients after anti-SARS-CoV-2 BNT162b2 vaccination (VC). In total, 32 CML patients with tyrosine kinase inhibitor (TKI) therapy, 10 CML patients with treatment-free remission, and 16 healthy subjects participated in the study. From April 2021 to September 2021, all cases (median age = 58 years) were vaccinated twice. Immunoglobulin G for SARS-CoV-2 spike protein (S-IgG) was measured at three timepoints (before the first VC, 1−5 weeks after the second VC (T1), and approximately 6 months after the second VC (T2)). S-IgG was not observed before the first VC in any participant. At T1, all cases had acquired S-IgG. There were no significant differences in S-IgG levels among groups. A paired sample comparison of median S-IgG titers between T1 and T2 in all groups showed a significant reduction in T2 S-IgG titers. There were no significant differences in S-IgG levels among groups. When all patients were analyzed, those aged ≥58 years had significantly lower S-IgG levels than those aged <58 years at T1. The BNT162b2 vaccine was highly effective in CML patients with or without TKIs, and S-IgG levels were as persistent as those in healthy individuals.
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25
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Shima H, Kada A, Tanizawa A, Sato I, Tono C, Ito M, Yuza Y, Watanabe A, Kamibeppu K, Uryu H, Koh K, Imai C, Yoshida N, Koga Y, Fujita N, Saito AM, Adachi S, Ishii E, Shimada H. Discontinuation of tyrosine kinase inhibitors in pediatric chronic myeloid leukemia. Pediatr Blood Cancer 2022; 69:e29699. [PMID: 35403816 DOI: 10.1002/pbc.29699] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/20/2022] [Accepted: 03/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The feasibility of tyrosine kinase inhibitor (TKI) discontinuation in pediatric chronic myeloid leukemia (CML) remains to be fully elucidated. PROCEDURES TKI was prospectively discontinued in patients who were diagnosed with CML at <20 years of age, treated with TKI for ≥3 years, and sustained molecular response 4.0 (MR4.0) for ≥2 years. Molecular relapse was defined as a single loss of major molecular response (MMR) (BCR-ABL1IS >0.1%). Relapsed patients resumed the same TKI therapy administered before discontinuation. RESULTS Twenty-two patients with chronic-phase CML were enrolled, and the median ages at diagnosis and at TKI discontinuation were 9 (range: 1-14) years and 16 (5-26) years, respectively. The median follow-up time after TKI discontinuation was 37 months (range: 24-41 months). The median duration of TKI treatment before discontinuation was 100 (42-178) months, and that of MR4.0 was 53.5 (25-148) months. The treatment-free remission (TFR) rate at 12 months was 50.0% (90% confidence interval: 31.7%-65.8%). Eleven patients experienced loss of MMR within 4 months after TKI discontinuation and resumed TKI as originally prescribed. No progression was observed, and all 11 patients regained MR4.0 after TKI resumption. No patient had a withdrawal syndrome. The quality-of-life analysis suggested that successful TFR may improve academic performance in some patients. In patients who discontinued TKI therapy before puberty, the possibility of improvement in growth velocity upon TKI discontinuation was observed. CONCLUSIONS TKI could be discontinued safely in patients with pediatric CML showing a sustained deep MR.
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Affiliation(s)
- Haruko Shima
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | | | - Iori Sato
- Department of Family Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chikako Tono
- Department of Pediatrics, Iwate Prefectural Chubu Hospital, Iwate, Japan
| | - Masaki Ito
- Department of Pediatrics, Soma General Hospital, Fukushima, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Akihiro Watanabe
- Department of Pediatrics, Niigata Cancer Center Hospital, Niigata, Japan
| | - Kiyoko Kamibeppu
- Department of Family Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideko Uryu
- Department of Pediatrics, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nao Yoshida
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Aichi, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naoto Fujita
- Department of Pediatrics, Hiroshima Red Cross Hospital & Atomic-Bomb Survivors Hospital, Hiroshima, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | | | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroyuki Shimada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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26
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[Observational study of chronic myeloid leukemia Chinese patients who discontinued tyrosine kinase inhibitors in the real-world]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:636-643. [PMID: 36709147 PMCID: PMC9593009 DOI: 10.3760/cma.j.issn.0253-2727.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: This study aimed to observe whether the treatment-free remission (TFR) of second-generation tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML) is better than imatinib (IM) . Methods: The clinical data of 274 CML patients who discontinued treatment and with complete clinical data were retrospectively studied from June 2013 to March 2021. Using both univariate and multivariate Cox proportional hazards regression models, risk factors influencing TFR outcomes after drug withdrawal in CML patients were assessed. Results: A total of 274 patients were enrolled, 140 patients were women (51.1%) , with a median age of 48 (9-84) years at the time of TKI discontinuation. Prior to TKI discontinuation, 172 (62.8%) patients were treated with IM, and 102 (37.2%) had received second-generation TKI treatment, including 73 patients who had shifted from IM to a second-generation TKI and 29 patients who used second-generation TKI as the first-line treatment. The rationale for converting to a second-generation TKI are as follows: 37 patients aimed deep molecular response (DMR) to achieve TFR, seven patients changed due to IM intolerance, and 29 patients changed because of failure to achieve the optimal treatment response. The use of the last type of TKI included 96 patients (94.1%) with nilotinib, three patients (2.9%) with dasatinib, and two patients (2%) with flumatinib, including one patient who changed to IM due to second-generation TKI intolerance. No statistical differences were found in the median age at diagnosis and TKI discontinuation, sex, Sokal score, IFN treatment before TKI, median time of TKI treatment to achieve DMR, and the reasons for TKI discontinuation between the second TKI and IM (P>0.05) .The median cumulative treatment time of TKI (71.5 months vs 88 months, P<0.001) , the last TKI median treatment time (60 months vs 88 months, P<0.001) , and the median duration of DMR (58 months vs 66 months, P=0.002) were significantly shorter in the second-generation TKI compared with IM. In the median follow-up of 22 (6-118) months after TKI discontinuation, 88 patients (32.1%) had lost their MMR at a median of 6 (1-91) months; of the 53 patients (60.2%) who lost MMR within 6 months, the overall TFR rate was 67.9%, and the cumulative TFR rates at 12 and 24 months were 70.5% and 67.5%, respectively. Withdrawal syndrome occurred in 26 patients (9.5%) . For patients who restarted TKI treatment, 72 patients (83.7%) achieved DMR again at a median treatment of 4 (1 to 18) months. The univariate analysis showed that the TFR rate of patients treated with second-generation TKI was significantly higher than those who were treated with IM (77.5% vs 62.2%, P=0.041) . A further subgroup analysis found that the TFR rate of the second-generation TKI patients was significantly higher than those treated with IM (80.8% vs 62.2%, P=0.026) . No significant difference was found in the second-generation TKI used as the first line treatment compared with those who were treated with IM (69.0% vs 62.2%, P=0.599) . The multivariate analysis results showed that second-generation TKI treatment was an independent prognostic factor affecting TFR in patients who discontinued TKI (RR=1.827, 95%CI 1.015-3.288, P=0.044) . Conclusion: In the clinical setting, more CML patients rapidly achieved TFR using second-generation TKI than IM treatment.
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27
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Boquimpani C, Seguro FS, Magalhães GHR, Pinto ILS, Bendit I, Bortolini JAP, Pagnano KBB, Centrone R, Funke V. Brazilian chronic myeloid leukemia working group recommendations for discontinuation of tyrosine kinase inhibitors in chronic myeloid leukemia in clinical practice. Hematol Transfus Cell Ther 2022; 44:402-409. [PMID: 35654721 PMCID: PMC9477780 DOI: 10.1016/j.htct.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/13/2022] [Accepted: 04/01/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Treatment-free remission (TFR) is a new goal of chronic myeloid leukemia (CML) therapy. TFR is feasible when the patient has achieved a deep and stable molecular response and met the criteria required to ensure its success. Treatment discontinuation should not be proposed to the CML patient if minimum conditions are not met. In Brazil, for example, molecular tests (BCR::ABL1) are not broadly available, making it difficult to monitor the patients adequately. Objective In this sense, providing TFR recommendations for Brazilian physicians are therefore necessary. These recommendations include the main criteria checklist to start the TKIs treatment discontinuing process in patients diagnosed with CML and the population-eligible characteristics for treatment discontinuation. Method Age, risk score at diagnosis, TKI treatment duration, BCR::ABL1 transcripts type, depth of the molecular response for treatment discontinuation, treatment adherence, patient monitoring and withdrawal syndrome are essential factors to consider in TFR. After TKI discontinuation, BCR::ABL1 transcripts monitoring should be more frequent. When a major molecular response loss is observed during the monitoring of a patient in TFR, the TKI treatment should be resumed. Conclusion These recommendations should serve as a basis for medical professionals interested in proposing TKI discontinuation for CML patients in clinical practice. It is important to highlight that, despite the benefits of TFR for the patients and the health system, it should only be feasible following the minimum standards proposed in this recommendation.
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28
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Xu Z, Yin J, Sun Q, Hu J, Hong M, Qian S, Liu W. The prognostic role of NKG2A expression for patients with chronic myeloid leukemia after treatment discontinuation. Leuk Lymphoma 2022; 63:2616-2626. [PMID: 35758278 DOI: 10.1080/10428194.2022.2090549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study aims to evaluate the possibility of tyrosine kinase inhibitors (TKIs) discontinuation in chronic myeloid leukemia (CML) patients who obtained sustained deep molecular response (DMR) and to explore the prognostic role of NK cells in treatment-free remission (TFR). Sixty CML patients who discontinued TKI treatment were enrolled, and we also investigated the immune profiles in 27 CML patients after TKI cessation. Of the 60 patients, the estimated TFR rate was 60.8% [95% CI: 49.5-74.8%] at 12 months. Patients who had longer TKI duration, major molecular response, and DMR maintenance time had a significantly higher TFR rate. And a higher percentage of NKG2A+NK cells and NKG2A+CD56brightCD16-NK cells were independent prognostic factors of TFR in multivariate analysis. These results indicate the practicality of the cessation of TKIs and patients with stable NK cell counts accompanied by higher cytotoxicity and increased killing capacity are more inclined to get sustained treatment-free survival.
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Affiliation(s)
- Ziyao Xu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Jinyu Yin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Qian Sun
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Jinhua Hu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Ming Hong
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Sixuan Qian
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Wenjie Liu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
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29
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Iurlo A, Cattaneo D, Artuso S, Consonni D, Abruzzese E, Binotto G, Bocchia M, Bonifacio M, Castagnetti F, Galimberti S, Gozzini A, Iezza M, Latagliata R, Luciano L, Maggi A, Miggiano MC, Pregno P, Rege-Cambrin G, Russo S, Scortechini AR, Tafuri A, Tiribelli M, Fava C, Rosti G, Foa R, Breccia M, Saglio G. Treatment-Free Remission in Chronic Myeloid Leukemia Patients Treated With Low-Dose TKIs: A Feasible Option Also in the Real-Life. A Campus CML Study. Front Oncol 2022; 12:839915. [PMID: 35311109 PMCID: PMC8927081 DOI: 10.3389/fonc.2022.839915] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/14/2022] [Indexed: 01/06/2023] Open
Abstract
Treatment-free remission (TFR) has become a primary therapeutic goal in CML and is also considered feasible by international guidelines. TKIs dose reduction is often used in real-life practice to reduce adverse events, although its impact on TFR is still a matter of debate. This study aimed to explore the attitude of Italian hematologists towards prescribing TKIs at reduced doses and its impact on TFR. In September 2020, a questionnaire was sent to 54 hematology centers in Italy participating to the Campus CML network. For each patient, data on the main disease characteristics were collected. Most of the hematologists involved (64.4%) believed that low-dose TKIs should not influence TFR. Indeed, this approach was offered to 194 patients. At the time of TFR, all but 3 patients had already achieved a DMR, with a median duration of 61.0 months. After a median follow-up of 29.2 months, 138 (71.1%) patients were still in TFR. Interestingly, TFR outcome was not impaired by any of the variables examined, including sex, risk scores, BCR-ABL1 transcript types, previous interferon, type and number of TKIs used before treatment cessation, degree of DMR or median duration of TKIs therapy. On the contrary, TFR was significantly better after dose reduction due to AEs; furthermore, patients with a longer DMR duration showed a trend towards prolonged TFR. This survey indicates that low-dose TKI treatment is an important reality. While one third of Italian hematologists still had some uncertainties on TFR feasibility after using reduced doses of TKIs outside of clinical trials, TFR has often been considered a safe option even in patients treated with low-dose TKIs in the real-life setting. It should be noted that only 28.9% of our cases had a molecular recurrence, less than reported during standard dose treatment. Consequently, TFR is not impaired using low-dose TKIs.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Silvia Artuso
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Gianni Binotto
- Department of Medicine, Hematology and Clinical Immunology, Padua School of Medicine, Padua, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Fausto Castagnetti
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, "S. Orsola-Malpighi" Hospital, Bologna, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Miriam Iezza
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, "S. Orsola-Malpighi" Hospital, Bologna, Italy
| | | | - Luigiana Luciano
- Division of Hematology, Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | | | | | - Patrizia Pregno
- Division of Hematology, AOU Città della Salute e della Scienza, Torino, Italy
| | - Giovanna Rege-Cambrin
- Division of Internal Medicine and Hematology, San Luigi Gonzaga Hospital, Turin, Italy
| | - Sabina Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Anna Rita Scortechini
- Division of Hematology, Department of Molecular and Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Agostino Tafuri
- Division of Hematology, Azienda Ospedaliera Universitaria Sant'Andrea, Rome, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Department of Medical and Morphological Research, University of Udine, Udine, Italy
| | - Carmen Fava
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Gianantonio Rosti
- Scientific Direction, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Robin Foa
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Division of Hematology, Department of Precision and Translational, Policlinico Umberto 1, Sapienza University, Rome, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
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30
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Kamachi K, Ureshino H, Watanabe T, Yoshida N, Yamamoto Y, Kurahashi Y, Fukuda-Kurahashi Y, Hayashi Y, Hirai H, Yamashita S, Ushijima T, Okada S, Kimura S. Targeting DNMT1 by demethylating agent OR-2100 increases tyrosine kinase inhibitors-sensitivity and depletes leukemic stem cells in chronic myeloid leukemia. Cancer Lett 2022; 526:273-283. [PMID: 34875342 DOI: 10.1016/j.canlet.2021.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022]
Abstract
ABL1 tyrosine kinase inhibitors (TKIs) dramatically improve the prognosis of chronic myeloid leukemia (CML), but 10-20% of patients achieve suboptimal responses with low TKIs sensitivity. Furthermore, residual leukemic stem cells (LSCs) are involved in the molecular relapse after TKIs discontinuation. Aberrant DNA hypermethylation contributes to low TKIs sensitivity and the persistence of LSCs in CML. DNMT1 is a key regulator of hematopoietic stem cells, suggesting that aberrant DNA hypermethylation targeting DNMT1 represents a potential therapeutic target for CML. We investigated the efficacy of OR-2100 (OR21), the first orally available single-compound prodrug of decitabine. OR21 exhibited anti-tumor effects as a monotherapy, and in combination therapy it increased TKI-induced apoptosis and induction of tumor suppressor genes including PTPN6 encoding SHP-1 in CML cells. OR21 in combination with imatinib significantly suppressed tumor growth in a xenotransplant model. OR21 and combination therapy decreased the abundance of LSCs and inhibited engraftment in a BCR-ABL1-transduced mouse model. These results demonstrate that targeting DNMT1 using OR21 exerts anti-tumor effects and impairs LSCs in CML. Therefore, combination treatment of TKIs and OR21 represents a promising treatment strategy in CML.
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Affiliation(s)
- Kazuharu Kamachi
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan; Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroshi Ureshino
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan; Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan.
| | - Tatsuro Watanabe
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Nao Yoshida
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuta Yamamoto
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuki Kurahashi
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan; OHARA Pharmaceutical Co., Ltd, Japan
| | - Yuki Fukuda-Kurahashi
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan; OHARA Pharmaceutical Co., Ltd, Japan
| | - Yoshihiro Hayashi
- Laboratory of Oncology, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Hideyo Hirai
- Laboratory of Stem Cell Regulation, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Satoshi Yamashita
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Seiji Okada
- Division of Hematopoiesis, Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan
| | - Shinya Kimura
- Department of Drug Discovery and Biomedical Sciences, Faculty of Medicine, Saga University, Saga, Japan; Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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31
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Réa D, Hughes TP. Development of Asciminib, a Novel Allosteric Inhibitor of BCR-ABL1. Crit Rev Oncol Hematol 2022; 171:103580. [PMID: 35021069 DOI: 10.1016/j.critrevonc.2022.103580] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 12/23/2021] [Accepted: 01/05/2022] [Indexed: 01/07/2023] Open
Abstract
Chronic myeloid leukemia (CML) is driven by a translocation event between chromosomes 9 and 22, leading to the formation of a constitutively active BCR-ABL1 oncoprotein. Approved tyrosine kinase inhibitors (TKIs) for CML inhibit BCR-ABL1 by competitively targeting its adenosine triphosphate (ATP)-binding site, which significantly improves patient outcomes. However, resistance to and intolerance of TKIs remains a clinical challenge. Asciminib is a promising investigational agent in development that allosterically targets BCR-ABL1 in a non-ATP-competitive manner. It binds to the ABL1 myristoyl-binding pocket and is effective against most ABL1 kinase domain mutations that confer resistance to ATP-competitive TKIs, including the T315I mutation. This review discusses unmet needs in the current CML treatment landscape, reports clinical data from asciminib trials that support the use of single-agent asciminib as third-line therapy and beyond, and explores the potential benefit of asciminib in combination with approved TKIs in earlier lines.
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Affiliation(s)
- Delphine Réa
- Department of Hématologie, Hôpital Saint-Louis, Paris, France.
| | - Timothy P Hughes
- South Australian Health and Medical Research Institute and University of Adelaide, Adelaide, SA, Australia.
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32
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Murai K, Ureshino H, Kumagai T, Tanaka H, Nishiwaki K, Wakita S, Inokuchi K, Fukushima T, Yoshida C, Uoshima N, Kiguchi T, Mita M, Aoki J, Kimura S, Karimata K, Usuki K, Shimono J, Chinen Y, Kuroda J, Matsuda Y, Nakao K, Ono T, Fujimaki K, Shibayama H, Mizumoto C, Takeoka T, Io K, Kondo T, Miura M, Minami Y, Ikezoe T, Imagawa J, Takamori A, Kawaguchi A, Sakamoto J, Kimura S. Low-dose dasatinib in older patients with chronic myeloid leukaemia in chronic phase (DAVLEC): a single-arm, multicentre, phase 2 trial. THE LANCET HAEMATOLOGY 2021; 8:e902-e911. [DOI: 10.1016/s2352-3026(21)00333-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 12/30/2022]
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33
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Cortes J, Pavlovsky C, Saußele S. Chronic myeloid leukaemia. Lancet 2021; 398:1914-1926. [PMID: 34425075 DOI: 10.1016/s0140-6736(21)01204-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 01/04/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Tyrosine-kinase inhibitors have changed the natural history of chronic myeloid leukaemia in such a way that patients with adequate access to these agents, who are properly managed, and who respond well to this treatment can expect a near-normal life expectancy. Achieving this goal requires an adequate understanding of the patient's treatment goals, careful monitoring for the achievement of optimal response hallmarks, implementation of proper interventions according to the attainment of such endpoints, adequate recognition and management of adverse events, and acknowledgment of the relevance of comorbidities. Treatment with tyrosine-kinase inhibitors, once considered lifelong, has become terminable for at least some patients, and promising new agents are emerging for those whose disease does not respond to any of the multiple therapeutic options currently available. If these advances reach all patients with chronic myeloid leukaemia, cure might eventually become a reality in most instances.
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Affiliation(s)
- Jorge Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, USA.
| | | | - Susanne Saußele
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
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34
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Nakamae M, Nakamae H, Hashimoto M, Koh H, Nakashima Y, Hirose A, Hino M. Predictive value of clinical examination parameters for cardiovascular adverse events during treatment of chronic myeloid leukemia with tyrosine kinase inhibitors. Int J Hematol 2021; 115:329-335. [PMID: 34787835 DOI: 10.1007/s12185-021-03259-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022]
Abstract
Treatment of chronic myelogenous leukemia (CML) requires management of long-term use of tyrosine kinase inhibitors (TKIs). Although cardiovascular adverse events (CAEs) caused by off-target effects of TKIs can be life-threatening, the optimal method of monitoring for CAEs has not been established. Here, we comprehensively evaluated the clinical utility of various cardiovascular parameters, including ankle-brachial blood pressure index (ABI), cardiac ankle vascular index (CAVI), and carotid ultrasonography and electrocardiogram measurements, for monitoring and predicting CAEs in 74 patients with CML receiving TKIs. Based on concordance statistics, the predictive value of established risk factor models was significantly improved by addition of both ABI and CAVI, as follows: model 1 (hypertension, smoking history, and dyslipidemia), 0.680 versus 0.817 (p = 0.041); model 2 (hypertension, dyslipidemia, and diabetes mellitus), 0.685 vs. 0.830 (p = 0.047); and model 3 (age, hypertension, dyslipidemia and diabetes mellitus) 0.737 versus 0.818 (p = 0.044). However, no single cardiovascular parameter independently improved the predictive value of established risk factor models. In conclusion, addition of combined assessment of ABI and CAVI to established risk factors can improve prediction of future CAEs and may enable better clinical management of patients with CML receiving TKIs.
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Affiliation(s)
- Mika Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Laboratory Medicine and Medical Informatics, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Clinical Laboratory, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Mika Hashimoto
- Department of Clinical Laboratory, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Asao Hirose
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Laboratory Medicine and Medical Informatics, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Clinical Laboratory, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
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35
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Chen Y, Zou J, Cheng F, Li W. Treatment-Free Remission in Chronic Myeloid Leukemia and New Approaches by Targeting Leukemia Stem Cells. Front Oncol 2021; 11:769730. [PMID: 34778088 PMCID: PMC8581243 DOI: 10.3389/fonc.2021.769730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/11/2021] [Indexed: 12/11/2022] Open
Abstract
The therapeutic landscape for chronic myeloid leukemia (CML) has improved significantly with the approval of tyrosine kinase inhibitors (TKIs) for therapeutic use. Most patients with optimal responses to TKIs can have a normal life expectancy. Treatment-free remission (TFR) after discontinuing TKI has increasingly become a new goal for CML treatment. However, TKI only "control" CML, and relapse after discontinuation has become a key factor hindering patient access to attempt TFR. In this study, we reviewed studies on TKI discontinuation, including both first and second-generation TKI. We also reviewed predictors of relapse, new monitoring methods, and strategies targeting leukemic stem cells.
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Affiliation(s)
| | | | | | - Weiming Li
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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36
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Which Tyrosine Kinase Inhibitors Should Be Selected as the First-Line Treatment for Chronic Myelogenous Leukemia in Chronic Phase? Cancers (Basel) 2021; 13:cancers13205116. [PMID: 34680265 PMCID: PMC8534191 DOI: 10.3390/cancers13205116] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/09/2021] [Accepted: 10/09/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary This review discusses the optimal selection of BCR-ABL1 tyrosine kinase inhibitors (TKIs) as the first-line treatment for newly diagnosed chronic myelogenous leukemia in chronic phase (CML-CP). With the advent of TKIs, the treatment goals for CML-CP patients have changed from “simply survival” to “survival with adequate quality of life”, hence the number of CML-CP patients aiming to achieve treatment-free remission has increased, irrespective of age or comorbidities. Therefore, optimal selection of TKIs for maximizing the number of patients to achieve treatment-free remission is an important factor for consideration in future studies. To this end, we must understand the advantages and disadvantages of each TKI in terms of treatment response, disease risk at diagnosis, comorbidities, and medical expenses, and use of effective 2GTKIs based on patient background. This review provides insights into “shared decision-making” in individual cases, including the elderly population. Abstract With the use of tyrosine kinase inhibitors (TKIs), chronic myelogenous leukemia in chronic phase (CML-CP) has been transformed into a non-fatal chronic disease. Hence, “treatment-free remission (TFR)” has become a possible treatment goal of patients with CML-CP. Currently, four types of TKIs (imatinib, nilotinib, dasatinib, and bosutinib) are used as the first-line treatment for newly diagnosed CML-CP. However, the second-generation TKI (2GTKI), the treatment response of which is faster and deeper than that of imatinib, is not always recommended as the first-line treatment for CML-CP. Factors involved in TKI selection in the first-line treatment of CML-CP include not only patients’ medical background, but also patients’ choice regarding the desired treatment goal (survival or TFR?). Therefore, it is important that clinicians select an appropriate TKI to successfully achieve the desired treatment goal for each patient, while minimizing the development of adverse events. This review compares the pros and cons of using imatinib and 2GTKI for TKI selection as the first-line treatment for CML-CP, mainly considering treatment outcomes, medical history (i.e., desire for pregnancy, aging factor, and comorbidity), and cost. The optimal use of 2GTKIs is also discussed.
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37
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How I Treat Chronic Phase Chronic Myelogenous Leukemia. Blood 2021; 139:3138-3147. [PMID: 34529784 DOI: 10.1182/blood.2021011722] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/23/2021] [Indexed: 11/20/2022] Open
Abstract
When imatinib, the first tyrosine kinase inhibitor (TKI) developed for use in chronic myelogenous leukemia (CML) was approved in 2001, the treatment of this disease was forever changed. Significant reductions in the molecular burden of disease were seen with the first generation TKI imatinib and with the addition of dasatinib (2006), nilotinib (2007), bosutinib (2012) and ponatinib (2013), deeper and more rapid reductions were noted. Physicians could begin to tailor TKI therapy to individual patients, and patients who did not respond to or could not tolerate first line therapy now had options. Importantly, the number of patients who developed accelerated or blast phase disease decreased dramatically. Research in CML continues to evolve and by presenting illustrative cases, this article will review some of the newer aspects of clinical care in this disease. Updated information regarding bosutinib and asciminib, the latter currently in clinical trials, will be presented; bosutinib is of particular interest as the drug's transit through the United States Food and Drug Administration (FDA) highlights the question of what is considered optimal response to TKI therapy. The challenge of understanding the cardiac safety data of ponatinib and the unique dosing schedule based on individual response will be discussed. Lastly, two cases will focus on features of TKI treatment that -remarkably- have become part of the treatment algorithm: family planning for women with CML and stopping therapy after meeting a specific treatment milestone.
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38
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Saifullah HH, Lucas CM. Treatment-Free Remission in Chronic Myeloid Leukemia: Can We Identify Prognostic Factors? Cancers (Basel) 2021; 13:cancers13164175. [PMID: 34439327 PMCID: PMC8392063 DOI: 10.3390/cancers13164175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Chronic myeloid leukemia (CML) is a blood cancer. Unlike other cancers CML treatment is lifelong and many patients experience side effects. For those patients who respond well to treatment and achieve deep molecular remission, quality of life is impacted because of continuous treatment. In this review, we look at emerging clinical trials which aim to investigate which patients can safely stop treatment. Treatment-free remission is the ultimate goal for CML patients, but there is still a gap in our knowledge as to why some patients can achieve treatment-free remission, while others relapse when treatment is stopped. Here we discuss if there are any prognostic factors that can predict the best candidates who qualify for treatment discontinuation, with a view to keeping them in remission. Abstract Following the development of tyrosine kinase inhibitors (TKI), the survival of patients with chronic myeloid leukaemia (CML) drastically improved. With the introduction of these agents, CML is now considered a chronic disease for some patients. Taking into consideration the side effects, toxicity, and high cost, discontinuing TKI became a goal for patients with chronic phase CML. Patients who achieved deep molecular response (DMR) and discontinued TKI, remained in treatment-free remission (TFR). Currently, the data from the published literature demonstrate that 40–60% of patients achieve TFR, with relapses occurring within the first six months. In addition, almost all patients who relapsed regained a molecular response upon retreatment, indicating TKI discontinuation is safe. However, there is still a gap in understanding the mechanisms behind TFR, and whether there are prognostic factors that can predict the best candidates who qualify for TKI discontinuation with a view to keeping them in TFR. Furthermore, the information about a second TFR attempt and the role of gradual de-escalation of TKI before complete cessation is limited. This review highlights the factors predicting success or failure of TFR. In addition, it examines the feasibility of a second TFR attempt after the failure of the first one, and the current guidelines concerning TFR in clinical practice.
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Affiliation(s)
- Hilbeen Hisham Saifullah
- Chester Medical School, University of Chester, Bache Hall, Chester CH2 1BR, UK
- Correspondence: (H.H.S.); (C.M.L.)
| | - Claire Marie Lucas
- Chester Medical School, University of Chester, Bache Hall, Chester CH2 1BR, UK
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool L69 3GA, UK
- Correspondence: (H.H.S.); (C.M.L.)
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Kwaśnik P, Giannopoulos K. Treatment-Free Remission-A New Aim in the Treatment of Chronic Myeloid Leukemia. J Pers Med 2021; 11:697. [PMID: 34442340 PMCID: PMC8399881 DOI: 10.3390/jpm11080697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 02/08/2023] Open
Abstract
Tyrosine kinases inhibitors (TKIs) revolutionized chronic myeloid leukemia (CML) treatment for many years, prolonging patients' life expectancy to be comparable to age-matched healthy individuals. According to the latest the European LeukemiaNet (ELN) recommendations, CML treatment aims to achieve long-term remission without treatment (TFR), which is feasible in more than 40% of patients. Nearly all molecular relapses occur during the first 6 months after TKI withdrawal and do not progress to clinical relapse. The mechanisms that are responsible for CML relapses remain unexplained. It is suggested that maintaining TFR is not directly related to the total disposing of the gene transcript BCR-ABL1, but it might be a result of the restoration of the immune surveillance in CML. The importance of the involvement of immunocompetent cells in the period of TKI withdrawal is also emphasized by the presence of specific symptoms in some patients with "withdrawal syndrome". The goal of this review is to analyze data from studies regarding TFRs in order to characterize the elements of the immune system of patients that might prevent CML molecular relapse. The role of modern droplet digital polymerase chain reaction (ddPCR) and next-generation sequencing (NGS) in better identification of low levels of BCR-ABL1 transcripts was also taken into consideration for refining the eligibility criteria to stop TKI therapy.
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Affiliation(s)
- Paulina Kwaśnik
- Department of Experimental Hematooncology, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Krzysztof Giannopoulos
- Department of Experimental Hematooncology, Medical University of Lublin, 20-093 Lublin, Poland;
- Department of Hematology, St John’s Cancer Center, 20-090 Lublin, Poland
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40
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Ureshino H, Kamachi K, Nishioka A, Okamoto S, Katsuya H, Yoshimura M, Kubota Y, Ando T, Kimura S. Subsequent attempt tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia; a single institute experience. Hematol Oncol 2021; 39:549-557. [PMID: 34117654 DOI: 10.1002/hon.2896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/12/2022]
Abstract
Discontinuation of tyrosine kinase inhibitors (TKIs) is now a feasible therapeutic goal for patients with chronic phase chronic myeloid leukemia (CML-CP). Whereas approximately half of patients experience molecular relapse, after resuming with any TKI; the majority re-achieve a deep molecular response (DMR). It is unclear whether such patients who re-achieve a durable DMR can discontinue TKI safely again. Here, we retrospectively assessed first, second, and third attempts to stop TKIs in patients with CML-CP. At the first attempt, 28 out of a total of 53 patients achieved sustained treatment-free remission (TFR; 53.4%; 95% confidence interval [CI], 39.0%-65.9%). Subsequently, 10 of 25 patients attempted a second TKI discontinuation, and in all cases, this was after receiving second-generation TKIs. Four of 10 patients successfully achieved TFR (37.5%; 95% CI, 9.9%-65.9%). All patients who relapsed at the second TKI discontinuation attempt were re-administered TKIs, and soon achieved at least a major molecular remission. All six second relapse patients had a loss of MR4.5 at 3 months after TKI discontinuation. These findings suggest that second and third attempts to successfully stop TKI treatment are feasible in patients with CML-CP.
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Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kazuharu Kamachi
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Atsujiro Nishioka
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Sho Okamoto
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Mariko Yoshimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yasushi Kubota
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Toshihiko Ando
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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41
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Late molecular recurrences in patients with chronic myeloid leukemia experiencing treatment-free remission. Blood Adv 2021; 4:3034-3040. [PMID: 32614963 DOI: 10.1182/bloodadvances.2020001772] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 01/15/2023] Open
Abstract
Treatment-free remission (TFR) is an opportunity for patients with chronic myeloid leukemia (CML). Reported cumulative incidence curves of molecular recurrence (MRec) arbor a 2-phase shape with mainly early events, but also some late events (late MRec [LMRec]). Having discontinued our first patient in 2004, we have access to a prolonged follow-up, enabling us to characterize these late events. Over 15 years, 128 patients from our institution were registered in the Stop Imatinib (STIM; A Study for Tyrosine Kinase Inhibitors Discontinuation [A-STIM]) trial. MRec was defined by the loss of major molecular response (BCR-ABL1IS >0.1%). At the first TFR attempt, patients had been taking a tyrosine kinase inhibitor for a median of 7.1 years and in BCR-ABL1IS ≤0.01% (MR4) for a median of 4 years. The median follow-up of patients in TFR was 6.5 years. The TFR rate was estimated to be 45.6% after 7 years. For 9/65 (14%) patients experiencing MRec, recurrence occurred after 2 years in TFR (median, 3.6 years). The residual rate of MRec after 2 years was estimated to be 18%. The probability of remaining in TFR was 65.4% for patients having experienced fluctuations of their minimal residual disease (MRD) (at least 2 consecutive measurements BCR-ABL1IS >0.0032% or loss of MR4), whereas it was 100% for those with stable MRD (P = .003). After 2 years in TFR, we observed an 18% residual rate of LMRec. These late events represent 14% of all MRec and occur in patients with fluctuating MRD measurements. A long-term molecular follow-up therefore remains mandatory for CML patients in TFR. The A-STIM study was registered at www.clinicaltrials.gov as #NCT02897245.
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42
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Ross DM. How much imatinib is enough? Br J Haematol 2021; 193:699-700. [PMID: 33876424 DOI: 10.1111/bjh.17444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David M Ross
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide, Australia.,Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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43
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Cerveira N, Bizarro S, Teixeira MR, Mariz JM. When to Stop TKIs in Patients with Chronic Myeloid Leukemia and How to Follow Them Subsequently. Curr Treat Options Oncol 2021; 22:49. [PMID: 33866455 DOI: 10.1007/s11864-021-00851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT ABL1 tyrosine kinase inhibitors (TKI) have dramatically improved the outcome for CML (chronic myeloid leukemia) patients. When TKI therapy is addressed appropriately, it can lead to an optimal molecular response in the majority of CML patients and a life expectancy that approaches that of the general population. However, lifelong TKI therapy may have consequences, including chronic, mostly low-grade, adverse events that can substantially impact patients' quality of life, adherence to therapy and, consequently, success of treatment. In the last few years, several groups have demonstrated that approximately 50% of chronic phase CML patients (CP-CML) who have achieved a stable deep molecular response (DMR) can stop therapy without suffering molecular relapse. Nowadays, treatment-free remission (TFR) has a significant role in the management of CML and should be considered in selected motivated patients that fulfill well-defined requirements to maximize the probability of successful discontinuation of TKI therapy.
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Affiliation(s)
- Nuno Cerveira
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.
| | - Susana Bizarro
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Manuel R Teixeira
- Serviço de Genética, Instituto Português de Oncologia do Porto, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.,Instituto de Ciências Biomédicas, Universidade do Porto, Porto, Portugal
| | - José M Mariz
- Serviço de Hematologia, Instituto Português de Oncologia do Porto, Porto, Portugal
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44
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Flygt H, Sandin F, Dahlén T, Dremaine A, Lübking A, Markevärn B, Myhr-Eriksson K, Olsson K, Olsson-Strömberg U, Själander A, Söderlund S, Wennström L, Wadenvik H, Stenke L, Höglund M, Richter J. Successful tyrosine kinase inhibitor discontinuation outside clinical trials - data from the population-based Swedish chronic myeloid leukaemia registry. Br J Haematol 2021; 193:915-921. [PMID: 33782950 DOI: 10.1111/bjh.17392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/14/2021] [Indexed: 11/30/2022]
Abstract
Clinical trials show that tyrosine kinase inhibitor (TKI) treatment can be discontinued in selected patients with chronic myeloid leukaemia (CML). Although updated CML guidelines support such procedure in clinical routine, data on TKI stopping outside clinical trials are limited. In this retrospective study utilising the Swedish CML registry, we examined TKI discontinuation in a population-based setting. Out of 584 patients diagnosed with chronic-phase CML (CML-CP) in 2007-2012, 548 had evaluable information on TKI discontinuation. With a median follow-up of nine years from diagnosis, 128 (23%) discontinued TKI therapy (≥1 month) due to achieving a DMR (deep molecular response) and 107 (20%) due to other causes (adverse events, allogeneic stem cell transplant, pregnancy, etc). Among those stopping in DMR, 49% re-initiated TKI treatment (median time to restart 4·8 months). In all, 38 patients stopped TKI within a clinical study and 90 outside a study. After 24 months 41·1% of patients discontinuing outside a study had re-initiated TKI treatment. TKI treatment duration pre-stop was longer and proportion treated with second-generation TKI slightly higher outside studies, conceivably affecting the clinical outcome. In summary we show that TKI discontinuation in CML in clinical practice is common and feasible and may be just as successful as when performed within a clinical trial.
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Affiliation(s)
- Hjalmar Flygt
- Department of Medical Science and Division of Hematology, University Hospital, Uppsala, Sweden
| | | | - Torsten Dahlén
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Arta Dremaine
- Department of Hematology, University Hospital, Linköping, Sweden
| | - Anna Lübking
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | | | | | - Ulla Olsson-Strömberg
- Department of Medical Science and Division of Hematology, University Hospital, Uppsala, Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Stina Söderlund
- Department of Medical Science and Division of Hematology, University Hospital, Uppsala, Sweden
| | - Lovisa Wennström
- Department of Hematology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hans Wadenvik
- Department of Hematology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Leif Stenke
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Martin Höglund
- Department of Medical Science and Division of Hematology, University Hospital, Uppsala, Sweden
| | - Johan Richter
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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45
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Osman AEG, Deininger MW. Chronic Myeloid Leukemia: Modern therapies, current challenges and future directions. Blood Rev 2021; 49:100825. [PMID: 33773846 DOI: 10.1016/j.blre.2021.100825] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/22/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022]
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm caused by a reciprocal translocation [t(9;22)(q34;q11.2)] that leads to the fusion of ABL1 gene sequences (9q34) downstream of BCR gene sequences (22q11) and is cytogenetically visible as Philadelphia chromosome (Ph). The resulting BCR/ABL1 chimeric protein is a constitutively active tyrosine kinase that activates multiple signaling pathways, which collectively lead to malignant transformation. During the early (chronic) phase of CML (CP-CML), the myeloid cell compartment is expanded, but differentiation is maintained. Without effective therapy, CP-CML invariably progresses to blast phase (BP-CML), an acute leukemia of myeloid or lymphoid phenotype. The development of BCR-AB1 tyrosine kinase inhibitors (TKIs) revolutionized the treatment of CML and ignited the start of a new era in oncology. With three generations of BCR/ABL1 TKIs approved today, the majority of CML patients enjoy long term remissions and near normal life expectancy. However, only a minority of patients maintain remission after TKI discontinuation, a status termed treatment free remission (TFR). Unfortunately, 5-10% of patients fail TKIs due to resistance and are at risk of progression to BP-CML, which is curable only with hematopoietic stem cell transplantation. Overcoming TKI resistance, improving the prognosis of BP-CML and improving the rates of TFR are areas of active research in CML.
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Affiliation(s)
- Afaf E G Osman
- Division of Hematology & Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Michael W Deininger
- Division of Hematology & Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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46
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Kimura S. Evolution of CML treatment. Int J Hematol 2021; 113:622-623. [PMID: 33721192 DOI: 10.1007/s12185-021-03128-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan.
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47
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Treatment-free remission and immunity in chronic myeloid leukemia. Int J Hematol 2021; 113:642-647. [PMID: 33651270 DOI: 10.1007/s12185-021-03117-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
Chronic myeloid leukemia (CML) is caused by the reciprocal translocation t(9;22)(q34;q11), resulting in the BCR-ABL1 fusion gene. BCR-ABL1 tyrosine kinase inhibitors (TKIs) improve overall survival in patients with chronic phase CML (CML-CP). Approximately half of the patients who achieve a durable deep molecular response can achieve sustained treatment-free remission (TFR) after TKI discontinuation; thus TFR is now a therapeutic goal for most patients with CML-CP. Sensitive BCL-ABL1 transcript detection methods reveal that evidence of residual CML cells remains in patients who achieve sustained TFR, indicating that the host immune system protects against CML relapse. The human immune system is composed of innate and adaptive arms. Natural killer cells are major components of the innate immune system, while T cells are major components of the adaptive immune system. Myeloid-derived suppressor cells and regulatory T cells, both suppressors of the immune response, have important roles in the regulation of CML. Here, we review the current understanding of the immune response in CML, especially in TFR.
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48
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Koyama D, Kikuchi J, Kuroda Y, Ohta M, Furukawa Y. AMP-activated protein kinase activation primes cytoplasmic translocation and autophagic degradation of the BCR-ABL protein in CML cells. Cancer Sci 2020; 112:194-204. [PMID: 33070465 PMCID: PMC7780059 DOI: 10.1111/cas.14698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/14/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022] Open
Abstract
Chronic myeloid leukemia is driven by the BCR‐ABL oncoprotein, a constitutively active protein tyrosine kinase. Although tyrosine kinase inhibitors (TKIs) have greatly improved the prognosis of CML patients, the emergence of TKI resistance is an important clinical problem, which deserves additional treatment options based on unique biological properties to CML cells. In this study, we show that metabolic homeostasis is critical for survival of CML cells, especially when the disease is in advanced stages. The BCR‐ABL protein activates AMP‐activated protein kinase (AMPK) for ATP production and the mTOR pathway to suppress autophagy. BCR‐ABL is detected in the nuclei of advanced‐stage CML cells, in which ATP is sufficiently supplied by enhanced glucose metabolism. AMP‐activated protein kinase is further activated under energy‐deprived conditions and triggers autophagy through ULK1 phosphorylation and mTOR inhibition. In addition, AMPK phosphorylates 14‐3‐3 and Beclin 1 to facilitate cytoplasmic translocation of nuclear BCR‐ABL in a BCR‐ABL/14‐3‐3τ/Beclin1/XPO1 complex. Cytoplasmic BCR‐ABL protein undergoes autophagic degradation when intracellular ATP is exhausted by disruption of the energy balance or forced autophagy flux with AMP mimetics, mTOR inhibitors, or arsenic trioxide, leading to apoptotic cell death. This pathway represents a novel therapeutic vulnerability that could be useful for treating TKI‐resistant CML.
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Affiliation(s)
- Daisuke Koyama
- Division of Stem Cell Regulation, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan.,Department of Internal Medicine, Fukushima Prefectural Miyashita Hospital, Mishima, Japan
| | - Jiro Kikuchi
- Division of Stem Cell Regulation, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yoshiaki Kuroda
- Division of Stem Cell Regulation, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Masatsugu Ohta
- Department of Hematology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Yusuke Furukawa
- Division of Stem Cell Regulation, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
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49
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Ross DM, Hughes TP. Counterpoint: There is a best duration of deep molecular response for treatment-free remission, but it is patient-specific, and that is the challenge. Br J Haematol 2020; 192:24-27. [PMID: 33169882 DOI: 10.1111/bjh.17111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/25/2020] [Indexed: 12/18/2022]
Abstract
There is considerable clinical and scientific interest in identifying reliable predictors of treatment-free remission in chronic myeloid leukaemia. Most predictors have been identified from non-randomized clinical trials or retrospective cohorts that could be subject to bias. The validity of predictive factors, such as duration of treatment or of deep molecular response, has been questioned. We briefly review the relevant data and the potential for bias, arguing that the risk of bias may be overstated, and that accumulating data strongly suggest that depth and duration of molecular response are critical factors to enable us to predict the probability of treatment-free remission.
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Affiliation(s)
- David M Ross
- Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,Flinders University and Medical Centre, Adelaide, Australia
| | - Timothy P Hughes
- Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia
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50
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Ureshino H, Shindo T, Tanaka H, Saji H, Kimura S. HLA Polymorphisms Are Associated with Treatment-Free Remission Following Discontinuation of Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia. Mol Cancer Ther 2020; 20:142-149. [PMID: 33082274 DOI: 10.1158/1535-7163.mct-20-0336] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/31/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022]
Abstract
Treatment-free remission (TFR) is one of the therapeutic goals for patients with chronic phase chronic myeloid leukemia (CML-CP). Although previous reports indicated that antitumor immunity contributes to TFR, its determinants are still unclear. We previously reported that allelic polymorphisms of killer immunoglobulin-like receptors (KIR) and human leukocyte antigens (HLA) are associated with achievement of deep molecular response (DMR) in patients with CML-CP. Here, we examined the association between TFR and polymorphisms of KIRs and HLAs in patients who discontinued tyrosine kinase inhibitors (TKI). Seventy-six patients were enrolled, and their KIR and HLA polymorphisms and natural killer (NK) cell activation status were investigated as previously described. Overall, 33 patients discontinued TKIs, and 21 of 33 achieved TFR [63.6%; 95% confidence interval (CI), 44.9%-77.5%] at 1 year. Multivariate analysis revealed that male sex (HR, 0.157; 95% CI, 0.031-0.804; P = 0.003) and HLA-A*02:01, *11:01, or *24:02 (HR, 6.386; 95% CI, 1.701-23.980; P = 0.006) were associated with TFR. Patients who achieved DMR and discontinued TKIs exhibited higher NK cell activation status than those who did not. By contrast, there were no significant differences in NK cell activation status between the patients who achieved TFR and those who experienced molecular relapse. These results suggest NK cell activation status contributes to achievement of DMR, whereas T-cell-mediated immunity contributes to TFR in patients with CML-CP.
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Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Saga University, Saga, Japan. .,Department of Drug Discovery and Biomedical Sciences, Saga University, Saga, Japan
| | - Takero Shindo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Saga University, Saga, Japan.,Department of Drug Discovery and Biomedical Sciences, Saga University, Saga, Japan
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