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Bnaya A, Ganzel C, Shavit L. Pseudohyperkalemia in chronic lymphocytic leukemia: Prevalence, impact, and management challenges. Am J Med Sci 2023; 366:167-175. [PMID: 37285937 DOI: 10.1016/j.amjms.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/14/2023] [Accepted: 04/17/2023] [Indexed: 06/09/2023]
Abstract
The term pseudohyperkalemia refers to a false elevation in serum potassium levels due to potassium release from cells in vitro. Falsely elevated potassium levels have been reported in patients with thrombocytosis, leukocytosis, and hematologic malignancies. This phenomenon has been particularly described in chronic lymphocytic leukemia (CLL). Leukocyte fragility, extremely high leukocyte counts, mechanical stress, higher cell membrane permeability related to an interaction with lithium heparin in plasma blood samples, and metabolite depletion due to a high leukocyte burden have been reported to contribute to pseudohyperkalemia in CLL. The prevalence of pseudohyperkalemia is up to 40%, particularly in the presence of a high leukocyte count (>50 × 109/L). The diagnosis of pseudohyperkalemia is often overlooked, which may result in unnecessary and potentially harmful treatment. The use of whole blood testing and point-of-care blood gas analysis, along with thorough clinical evaluation, may help differentiate between true and pseudohyperkalemic episodes.
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Affiliation(s)
- Alon Bnaya
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Chezi Ganzel
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Linda Shavit
- Institute of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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2
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Salter B, Burns I, Fuller K, Eshaghpour A, Lionel AC, Crowther M. Tyrosine kinase inhibitors and tumor lysis syndrome in hematologic malignancies: A systemic review. Eur J Haematol 2022; 109:166-181. [PMID: 35531791 DOI: 10.1111/ejh.13786] [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: 03/23/2022] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Effective treatments for hematologic malignancies include therapies that target tyrosine kinase (TK) signaling pathways. Tumor lysis syndrome (TLS) is an oncologic emergency that can occur due to rapid turnover following the initiation of treatments for hematologic malignancy. The incidence of TLS is under-reported and it is unclear as to whether TK inhibitors (TKIs) are associated with TLS. OBJECTIVE To conduct a systematic review to determine the incidence of TLS with TKIs. METHODS A search was performed using EMBASE, MEDLINE, and Web of Science electronic databases, as well as a manual search of the American Society of Hematology and American Society of Clinical Oncology abstract databases. Keywords included: "tumor lysis syndrome," "tyrosine kinase inhibitors," "lymphoma," and "leukemia." RESULTS We identified a total of 57 publications that commented on the incidence of TLS with TKIs for hematologic malignancy. Thirty-nine of those publications reported TLS as an adverse event. TLS was described as an adverse event among essentially all the subclasses of TKIs that are used to manage hematologic malignancies. CONCLUSION The overall number of articles commenting on TLS as an adverse event is sparse and there needs to be more transparency regarding the incidence of TLS when employing newer targeted therapies. Physicians should consider the risk of TLS on an individual basis and the added risk of TLS when using TKIs to treat hematologic malignancy.
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Affiliation(s)
| | - Ian Burns
- McMaster University, Hamilton, Ontario, Canada
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3
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Faber EB, Wang N, Georg GI. Review of rationale and progress toward targeting cyclin-dependent kinase 2 (CDK2) for male contraception†. Biol Reprod 2021; 103:357-367. [PMID: 32543655 PMCID: PMC7523694 DOI: 10.1093/biolre/ioaa107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/03/2020] [Accepted: 04/19/2020] [Indexed: 12/30/2022] Open
Abstract
Cyclin-dependent kinase 2 (CDK2) is a member of the larger cell cycle regulating CDK family of kinases, activated by binding partner cyclins as its name suggests. Despite its canonical role in mitosis, CDK2 knockout mice are viable but sterile, suggesting compensatory mechanisms for loss of CDK2 in mitosis but not meiosis. Here, we review the literature surrounding the role of CDK2 in meiosis, particularly a cyclin-independent role in complex with another activator, Speedy 1 (SPY1). From this evidence, we suggest that CDK2 could be a viable nonhormonal male contraceptive target. Finally, we review the literature of pertinent CDK2 inhibitors from the preclinical to clinical stages, mostly developed to treat various cancers. To date, there is no potent yet selective CDK2 inhibitor that could be repurposed as a contraceptive without appreciable off-target toxicity. To achieve selectivity for CDK2 over closely related kinases, developing compounds that bind outside the conserved adenosine triphosphate-binding site may be necessary.
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Affiliation(s)
- Erik B Faber
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota-Twin Cities, Minneapolis, MN, USA.,Medical-Scientist Training Program, University of Minnesota Medical School, University of Minnesota-Twin Cities, Minneapolis, MN, USA
| | - Nan Wang
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota-Twin Cities, Minneapolis, MN, USA
| | - Gunda I Georg
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota-Twin Cities, Minneapolis, MN, USA
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4
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Ozturk E, Erdogan Ozunal I. A Rare Side Effect of Ibrutinib: Tumor Lysis Syndrome. Medeni Med J 2021; 36:176-179. [PMID: 34239769 PMCID: PMC8226401 DOI: 10.5222/mmj.2021.56424] [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: 04/25/2021] [Accepted: 06/12/2021] [Indexed: 11/05/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a progressive disease with an indolent course, and tumor lysis syndrome (TLS) is rarely seen in CLL. Ibrutinib is a novel bruton kinase (BTK) inhibitor increasingly used in CLL treatment. Ibrutinib has significant side effects such as atrial fibrillation, bleeding, diarrhea, and infections. However, TLS is reported rarely with ibrutinib treatment. This report focuses on a 69-year-old female patient diagnosed with relapsed CLL who developed grade 4 TLS after ibrutinib monotherapy. The patient developed TLS on the third day of ibrutinib treatment necessitating discontinuation of the treatment and initiation of hemodialysis and supportive care. Ibrutinib treatment was re-initiated at a daily dose of 140 mg therapy after an interval of seven days, and then any additional side effect was not seen. Tumor lysis syndrome secondary to ibrutinib has been reported in an increasing number of cases. There is currently no information on managing adverse effects of TLS attributed to ibrutinib. Consequently, ibrutinib treatment of this patient was not terminated, and restarted after a short interval. It must not be forgotten that TLS secondary to ibrutinib treatment may be rarely seen, and can be life-threatening. Treatment with ibrutinib should be initiated in consideration of this side effect, and the development of complication of TLS may not necessitate discontinuation of ibrutinib treatment.
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Affiliation(s)
- Erman Ozturk
- Istanbul Medeniyet University Faculty of Medicine, Department of Hematology, Istanbul, Turkey
| | - Isıl Erdogan Ozunal
- Goztepe Prof Dr Suleyman Yalcın City Hospital, Department of Hematology, Istanbul, Turkey
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5
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Chen KTJ, Militao GGC, Anantha M, Witzigmann D, Leung AWY, Bally MB. Development and characterization of a novel flavopiridol formulation for treatment of acute myeloid leukemia. J Control Release 2021; 333:246-257. [PMID: 33798663 DOI: 10.1016/j.jconrel.2021.03.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/22/2021] [Accepted: 03/27/2021] [Indexed: 12/17/2022]
Abstract
For more than 30 years, treatment of acute myeloid leukemia (AML) has remained largely unchanged and reliant on chemotherapeutic drug combinations, specifically cytarabine and daunorubicin (the 7 + 3 regimen). One broad spectrum drug, flavopiridol (also known as Alvocidib) has shown significant activity against AML through the inhibition of cyclin-dependent kinases. Flavopiridol is a semisynthetic flavonoid and our research team recently described methods to formulate another flavonoid, quercetin, through the ability of flavonoids to bind divalent metals. This method relies on use of copper-containing liposomes to enhance the apparent solubility of flavopiridol and to create formulations suitable for intravenous (i.v.) use. Similar to quercetin, flavopiridol is defined as an aqueous-insoluble compound (< 1 mg/mL in water) and this research sought to evaluate whether the copper-binding capabilities of flavopiridol could be used to prepare an injectable formulation that would exhibit enhanced exposure and improved efficacy. Flavopiridol powder was added directly to preformed copper-containing liposomes (DSPC:Chol or DSPC:DSPE-PEG2000) and the resulting formulations were characterized. Pharmacokinetic and efficacy studies were then conducted. The liposomal flavopiridol formulations were well-tolerated in mice following i.v. administration at a dose of 5 mg/kg with no apparent acute or chronic toxicities. In vivo pharmacokinetics of the optimized DSPC/DSPE-PEG2000 liposomal flavopiridol formulation demonstrated a 30-fold increase in AUC (0.804 μg-hr/mL versus 26.92 μg-hr/mL) compared to the free flavopiridol formulation. The resultant liposomal formulation also demonstrated significant therapeutic activity in MV4-11 and MOLM-13 subcutaneous AML models. Additional studies will be required to define whether formulation changes can be made to enhance flavopiridol retention in the selected composition. The results suggest that further increases in flavopiridol retention will result in improved therapeutic activity.
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Affiliation(s)
- Kent T J Chen
- Department of Experimental Therapeutics, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada; Department of Interdisciplinary Oncology, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada.
| | - Gardenia G C Militao
- Department of Experimental Therapeutics, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada; Federal University of Pernambuco, PE CEP:50.670-901, Brazil
| | - Malathi Anantha
- Department of Experimental Therapeutics, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada
| | - Dominik Witzigmann
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, BC V6T 2B5, Canada; NanoMedicines Innovation Network (NMIN), University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Ada W Y Leung
- Department of Experimental Therapeutics, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada; Cuprous Pharmaceuticals, Vancouver, BC V6T 1Z3, Canada
| | - Marcel B Bally
- Department of Experimental Therapeutics, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V6T 2B5, Canada; Cuprous Pharmaceuticals, Vancouver, BC V6T 1Z3, Canada; NanoMedicines Innovation Network (NMIN), University of British Columbia, Vancouver, BC V6T 1Z3, Canada; Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 2B5, Canada
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6
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Ammazzalorso A, Agamennone M, De Filippis B, Fantacuzzi M. Development of CDK4/6 Inhibitors: A Five Years Update. Molecules 2021; 26:molecules26051488. [PMID: 33803309 PMCID: PMC7967197 DOI: 10.3390/molecules26051488] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 12/24/2022] Open
Abstract
The inhibition of cyclin dependent kinases 4 and 6 plays a role in aromatase inhibitor resistant metastatic breast cancer. Three dual CDK4/6 inhibitors have been approved for the breast cancer treatment that, in combination with the endocrine therapy, dramatically improved the survival outcomes both in first and later line settings. The developments of the last five years in the search for new selective CDK4/6 inhibitors with increased selectivity, treatment efficacy, and reduced adverse effects are reviewed, considering the small-molecule inhibitors and proteolysis-targeting chimeras (PROTACs) approaches, mainly pointing at structure-activity relationships, selectivity against different kinases and antiproliferative activity.
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7
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Julve M, Clark JJ, Lythgoe MP. Advances in cyclin-dependent kinase inhibitors for the treatment of melanoma. Expert Opin Pharmacother 2020; 22:351-361. [PMID: 33030382 DOI: 10.1080/14656566.2020.1828348] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Despite the recent advances in the treatment of malignant melanoma with immunotherapy and BRAF/MEK targeted agents, advanced disease still beholds a poor prognosis for a significant proportion of patients. Cyclin-dependent kinase (CDK) inhibitors have been investigated as novel melanoma therapeutics throughout a range of phase 1 and 2 trials, as single agents and in combination with established treatments. Areas covered: This article summarizes the rationale for, and development of CDK inhibitors in melanoma, with their evolution from pan-CDK inhibitors to highly specific agents, throughout clinical trials and finally their potential future use. Expert opinion: Whilst CDK inhibitors have been practice changing in breast cancer management, their efficacy is yet to be proven in melanoma. Combination with BRAF/MEK inhibitors has been hindered by dose-limiting toxicities, but their role may yet to be found within the spectrum of biomarker-derived personalized melanoma management. The effect that CDK inhibitors can have as an adjunct to immunotherapy also remains to be seen.
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Affiliation(s)
- Maximilian Julve
- Department of Surgery & Cancer, Imperial College London , London, UK
| | - James J Clark
- Department of Surgery & Cancer, Imperial College London , London, UK
| | - Mark P Lythgoe
- Department of Surgery & Cancer, Imperial College London , London, UK
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8
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Matuszkiewicz-Rowinska J, Malyszko J. Prevention and Treatment of Tumor Lysis Syndrome in the Era of Onco-Nephrology Progress. Kidney Blood Press Res 2020; 45:645-660. [DOI: 10.1159/000509934] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022] Open
Abstract
Background: Tumor lysis syndrome (TLS) is an oncologic emergency due to a rapid break down of malignant cells usually induced by cytotoxic therapy, with hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and serious clinical consequences such as acute renal injury, cardiac arrhythmia, hypotension, and death. Rapidly expanding knowledge of cancer immune evasion mechanisms and host-tumor interactions has significantly changed our therapeutic strategies in hemato-oncology what resulted in the expanding spectrum of neoplasms with a risk of TLS. Summary: Since clinical TLS is a life-threatening condition, identifying patients with risk factors for TLS development and implementation of adequate preventive measures remains the most critical component of its medical management. In general, these consist of vigilant laboratory and clinical monitoring, vigorous IV hydration, urate-lowering therapy, avoidance of exogenous potassium, use of phosphate binders, and – in high-risk cases – considering cytoreduction before the start of the aggressive agent or a gradual escalation of its dose. Key Messages: In patients with a high risk of TLS, cytotoxic chemotherapy should be given in the facility with ready access to dialysis and a treatment plan discussed with the nephrology team. In the case of hyperkalemia, severe hyperphosphatemia or acidosis, and fluid overload unresponsive to diuretic therapy, the early renal replacement therapy (RRT) should be considered. One must remember that in TLS, the threshold for RRT initiation may be lower than in other clinical situations since the process of cell breakdown is ongoing, and rapid increases in serum electrolytes cannot be predicted.
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9
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Anderson MA, Seymour JF. Tumor lysis syndrome: still the Achilles heel of venetoclax in treatment of CLL? Leuk Lymphoma 2020; 61:2286-2288. [DOI: 10.1080/10428194.2020.1802454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Mary Ann Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Parkville, Australia
| | - John Francis Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Medicine Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
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10
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Laham-Karam N, Pinto GP, Poso A, Kokkonen P. Transcription and Translation Inhibitors in Cancer Treatment. Front Chem 2020; 8:276. [PMID: 32373584 PMCID: PMC7186406 DOI: 10.3389/fchem.2020.00276] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Transcription and translation are fundamental cellular processes that govern the protein production of cells. These processes are generally up regulated in cancer cells, to maintain the enhanced metabolism and proliferative state of these cells. As such cancerous cells can be susceptible to transcription and translation inhibitors. There are numerous druggable proteins involved in transcription and translation which make lucrative targets for cancer drug development. In addition to proteins, recent years have shown that the "undruggable" transcription factors and RNA molecules can also be targeted to hamper the transcription or translation in cancer. In this review, we summarize the properties and function of the transcription and translation inhibitors that have been tested and developed, focusing on the advances of the last 5 years. To complement this, we also discuss some of the recent advances in targeting oncogenes tightly controlling transcription including transcription factors and KRAS. In addition to natural and synthetic compounds, we review DNA and RNA based approaches to develop cancer drugs. Finally, we conclude with the outlook to the future of the development of transcription and translation inhibitors.
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Affiliation(s)
- Nihay Laham-Karam
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Gaspar P. Pinto
- International Clinical Research Center, St. Anne University Hospital, Brno, Czechia
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
| | - Antti Poso
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- University Hospital Tübingen, Department of Internal Medicine VIII, University of Tübingen, Tübingen, Germany
| | - Piia Kokkonen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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11
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Mirzaei HR, Mirzaei H, Namdar A, Rahmati M, Till BG, Hadjati J. Predictive and therapeutic biomarkers in chimeric antigen receptor T‐cell therapy: A clinical perspective. J Cell Physiol 2018; 234:5827-5841. [DOI: 10.1002/jcp.27519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/10/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Hamid Reza Mirzaei
- Department of Medical Immunology School of Medicine, Tehran University of Medical Sciences Tehran Iran
| | - Hamed Mirzaei
- Department of Medical Biotechnology School of Medicine, Mashhad University of Medical Sciences Mashahd Iran
| | - Afshin Namdar
- Department of Dentistry Faculty of Medicine and Dentistry, University of Alberta Edmonton Canada
| | - Majid Rahmati
- Cancer Prevention Research Center Shahroud University of Medical Sciences Shahroud Iran
| | - Brian G. Till
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA United States
| | - Jamshid Hadjati
- Department of Medical Immunology School of Medicine, Tehran University of Medical Sciences Tehran Iran
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12
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Wanchoo R, Bernabe Ramirez C, Barrientos J, Jhaveri KD. Renal involvement in chronic lymphocytic leukemia. Clin Kidney J 2018; 11:670-680. [PMID: 30288263 PMCID: PMC6165759 DOI: 10.1093/ckj/sfy026] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/26/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most commonly diagnosed adult leukemia in the USA and Western Europe. Kidney disease can present in patients with CLL as a manifestation of the disease process such as acute kidney injury with infiltration or with a paraneoplastic glomerular disease or as a manifestation of extra renal obstruction and tumor lysis syndrome. In the current era of novel targeted therapies, kidney disease can also present as a complication of treatment. Tumor lysis syndrome associated with novel agents such as the B-cell lymphoma 2 inhibitor venetoclax and the monoclonal antibody obinutuzumab are important nephrotoxicities associated with these agents. Here we review the various forms of kidney diseases associated with CLL and its therapies.
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Affiliation(s)
- Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Carolina Bernabe Ramirez
- Division of Hematology and Oncology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Jacqueline Barrientos
- Division of Hematology and Oncology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
- CLL Research and Treatment Program, Lake Success, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
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13
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Tumor Lysis Syndrome in Patients with Hematological Malignancies. JOURNAL OF ONCOLOGY 2017; 2017:9684909. [PMID: 29230244 PMCID: PMC5688348 DOI: 10.1155/2017/9684909] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/01/2017] [Accepted: 10/12/2017] [Indexed: 02/05/2023]
Abstract
Tumor lysis syndrome is a metabolic complication that may follow the initiation of cancer therapy. It commonly occurs in hematological malignant patients particularly non-Hodgkin's lymphoma and acute leukemia due to chemotherapy or spontaneously. It is characterized by a biochemical abnormality such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia and its clinical outcome is directly related to these biochemical abnormalities. Prevention and treatment of tumor lysis syndrome depend on immediate recognition of patients at risk. Therefore, identifying patients at risk and prophylactic measures are important to minimize the clinical consequences of tumor lysis syndrome. Patients with low risk should receive hydration and allopurinol. On the other hand patients with high risk should receive hydration and rasburicase in an inpatient setting. It is important to start therapy immediately, to correct all parameters before cancer treatment, to assess risk level of patients for TLS, and to select treatment options based on the risk level. In this review a comprehensive search of literatures was performed using MEDLINE/PubMed, Hinari, the Cochrane library, and Google Scholar to summarize diagnostic criteria, incidence, predicting factors, prevention, and treatment options for tumor lysis syndrome in patients with hematological malignancies.
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Cheson BD, Heitner Enschede S, Cerri E, Desai M, Potluri J, Lamanna N, Tam C. Tumor Lysis Syndrome in Chronic Lymphocytic Leukemia with Novel Targeted Agents. Oncologist 2017; 22:1283-1291. [PMID: 28851760 PMCID: PMC5679833 DOI: 10.1634/theoncologist.2017-0055] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/10/2017] [Indexed: 12/22/2022] Open
Abstract
Tumor lysis syndrome (TLS) is an uncommon but potentially life-threatening complication associated with the treatment of some cancers. If left untreated, TLS may result in acute renal failure, cardiac dysrhythmia, neurologic complications, seizures, or death. Tumor lysis syndrome is most commonly observed in patients with hematologic malignancies with a high proliferation rate undergoing treatment with very effective therapies. In chronic lymphocytic leukemia (CLL), historically, TLS has been observed less often, owing to a low proliferation rate and slow response to chemotherapy. New targeted therapies have recently been approved in the treatment of CLL, including the oral kinase inhibitors, idelalisib and ibrutinib, and the B-cell lymphoma-2 protein inhibitor, venetoclax. Several others are also under development, and combination strategies of these agents are being explored. This review examines the diagnosis, prevention, and management of TLS and summarizes the TLS experience in CLL clinical trials with newer targeted agents. Overall, the risk of TLS is small, but the consequences may be fatal; therefore, patients should be monitored carefully. Therapies capable of eliciting rapid response and combination regimens are increasingly being evaluated for treatment of CLL, which may pose a higher risk of TLS. For optimal management, patients at risk for TLS require prophylaxis and close monitoring with appropriate tests and appropriate management to correct laboratory abnormalities, which allows for safe and effective disease control. IMPLICATIONS FOR PRACTICE Tumor lysis syndrome (TLS) is a potentially fatal condition observed with hematologic malignancies, caused by release of cellular components in the bloodstream from rapidly dying tumor cells. The frequency and severity of TLS is partly dependent upon the biology of the disease and type of therapy administered. Novel targeted agents highly effective at inducing rapid cell death in chronic lymphocytic leukemia (CLL) may pose a risk for TLS in patients with tumors characterized by rapid growth, high tumor burden, and/or high sensitivity to treatment. In this review, prevention strategies and management of patients with CLL who develop TLS are described.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Disease Management
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/prevention & control
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/genetics
- Purines/therapeutic use
- Quinazolinones/therapeutic use
- Risk Factors
- Sulfonamides/therapeutic use
- Tumor Burden
- Tumor Lysis Syndrome/complications
- Tumor Lysis Syndrome/diagnosis
- Tumor Lysis Syndrome/drug therapy
- Tumor Lysis Syndrome/prevention & control
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Affiliation(s)
- Bruce D Cheson
- Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | | | | | | | | | - Nicole Lamanna
- Columbia University Medical Center, New York, New York, USA
| | - Constantine Tam
- St Vincent's Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
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15
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Acute Kidney Injury in Hematopoietic Stem Cell Transplantation: A Review. Int J Nephrol 2016; 2016:5163789. [PMID: 27885340 PMCID: PMC5112319 DOI: 10.1155/2016/5163789] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/04/2016] [Accepted: 10/11/2016] [Indexed: 01/13/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a highly effective treatment strategy for lymphoproliferative disorders and bone marrow failure states including aplastic anemia and thalassemia. However, its use has been limited by the increased treatment related complications, including acute kidney injury (AKI) with an incidence ranging from 20% to 73%. AKI after HSCT has been associated with an increased risk of mortality. The incidence of AKI reported in recipients of myeloablative allogeneic transplant is considerably higher in comparison to other subclasses mainly due to use of cyclosporine and development of graft-versus-host disease (GVHD) in allogeneic groups. Acute GVHD is by itself a major independent risk factor for the development of AKI in HSCT recipients. The other major risk factors are sepsis, nephrotoxic medications (amphotericin B, acyclovir, aminoglycosides, and cyclosporine), hepatic sinusoidal obstruction syndrome (SOS), thrombotic microangiopathy (TMA), marrow infusion toxicity, and tumor lysis syndrome. The mainstay of management of AKI in these patients is avoidance of risk factors contributing to AKI, including use of reduced intensity-conditioning regimen, close monitoring of nephrotoxic medications, and use of alternative antifungals for prophylaxis against infection. Also, early identification and effective management of sepsis, tumor lysis syndrome, marrow infusion toxicity, and hepatic SOS help in reducing the incidence of AKI in HSCT recipients.
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Awan FT, Jones JA, Maddocks K, Poi M, Grever MR, Johnson A, Byrd JC, Andritsos LA. A phase 1 clinical trial of flavopiridol consolidation in chronic lymphocytic leukemia patients following chemoimmunotherapy. Ann Hematol 2016; 95:1137-43. [PMID: 27118540 DOI: 10.1007/s00277-016-2683-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/18/2016] [Indexed: 12/17/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) who receive chemoimmunotherapy and do not achieve complete remission experience significantly shortened progression-free interval (PFS). Additionally, the majority of patients treated for relapsed disease demonstrate evidence of measurable disease. Eradication of minimal residual disease (MRD) results in improved PFS and overall survival. Maintenance therapy might result in eradication of MRD and improve response duration but might be associated with an increase in incidence of infectious complications. Flavopiridol is a broad cyclin-dependent kinase (CDK) inhibitor with established safety and efficacy in patients with relapsed CLL, particularly patients with high-risk cytogenetic features. A pharmacologically derived schedule was utilized as consolidation therapy in this phase I study to assess the safety and feasibility of outpatient therapy with flavopiridol in patients with low tumor burden. Flavopiridol was administered as a 30-min loading dose of 30 mg/m(2) followed by a 4-h infusion of 30 mg/m(2) once weekly for 3 weeks every 5 weeks (1 cycle) for planned 2 cycles in ten patients. Therapy was extremely well tolerated and no patient developed acute tumor lysis syndrome. The most common toxicities were gastrointestinal. Of the patients, 22 % improved their response from a PR to CR. Eighty-eight percent experienced a reduction in tumor burden as measured by extent of bone marrow involvement including patients with del17p and complex karyotype. The study establishes the safety and efficacy of flavopiridol as consolidation therapy after chemoimmunotherapy for patients with CLL. Further evaluation is required in larger trials for the utility of CDK inhibitors as consolidation or maintenance strategies.Registration number at ClinicalTrials.gov: NCT00377104.
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Affiliation(s)
- Farrukh T Awan
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
| | - Jeffrey A Jones
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Kami Maddocks
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Ming Poi
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Michael R Grever
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Amy Johnson
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - John C Byrd
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Leslie A Andritsos
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
- Starling Loving Hall, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
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17
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Wiernik PH. Alvocidib (flavopiridol) for the treatment of chronic lymphocytic leukemia. Expert Opin Investig Drugs 2016; 25:729-34. [PMID: 26998706 DOI: 10.1517/13543784.2016.1169273] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Alvocidib, which has orphan drug designation in chronic lymphocytic leukemia (CLL) from the FDA and the EMA, is a plant-derived semisynthetic flavone that acts as a cyclin-dependent kinase inhibitor. It induces apoptosis in CLL cells in vitro and was introduced into clinical trials in CLL as an intravenous infusion in 1997, which proved disappointing. Since the drug avidly binds to plasma proteins, higher serum concentrations were required for clinical antileukemia activity than those suggested by in vitro studies. Subsequent studies utilizing bolus plus infusional doses revealed significant activity against CLL, even in patients with unfavorable characteristics. However, significant toxicity including high rates of major tumor lysis syndrome, cytokine release syndrome and secretory diarrhea were also observed. AREAS COVERED The chemistry, pharmacodynamics, pharmacokinetics and metabolism of alvocidib are briefly discussed and phase I-II studies in CLL are discussed in detail. To date, no phase III studies in CLL have been reported. EXPERT OPINION A number of much less toxic drugs with similar efficacy against CLL both with and without unfavorable cytogenetics have come to market. Furthermore, enthusiasm for the development of alvocidib as a single agent for the treatment of CLL has waned, primarily due to its toxicity.
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18
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Abstract
Inhibitors of B cell receptor signaling substantially changed the treatment of chronic lymphocytic leukemia as the first targeted agents to enter routine clinical practice. A recent paper by Roberts and colleagues describes an additional therapeutic target by reporting encouraging clinical results with venetoclax, an inhibitor of the antiapoptotic protein BCL2.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, The Ohio State University, Columbus, OH 43210, USA
| | - John C Byrd
- Division of Hematology, The Ohio State University, Columbus, OH 43210, USA.
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Zeidner JF, Karp JE. Clinical activity of alvocidib (flavopiridol) in acute myeloid leukemia. Leuk Res 2015; 39:1312-8. [PMID: 26521988 DOI: 10.1016/j.leukres.2015.10.010] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/01/2015] [Accepted: 10/14/2015] [Indexed: 10/25/2022]
Abstract
There have been minimal therapeutic advancements in acute myeloid leukemia (AML) over the past 4 decades and outcomes remain unsatisfactory. Alvocidib (formerly flavopiridol) is a multi-serine threonine cyclin-dependent kinase inhibitor with demonstrable in vitro and clinical activity in AML when combined in a timed sequential chemotherapy regimen, FLAM (alvocidib followed by cytarabine continuous infusion and mitoxantrone). FLAM has been evaluated in sequential phase 1 and phase 2 studies in 149 and 256 relapsed/refractory and newly diagnosed non-favorable risk AML patients, respectively, with encouraging findings in both patient populations warranting further investigation. This review highlights the mechanism of action of alvocidib, pre-clinical studies of alvocidib in AML, and the clinical trials evaluating alvocidib alone and in combination with cytotoxic agents (FLAM) in AML.
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Affiliation(s)
- Joshua F Zeidner
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States.
| | - Judith E Karp
- Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
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20
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Huang Y, Wu JZ, Li JY, Xu W. Know the enemy as well as the weapons in hand: the aberrant death pathways and therapeutic agents in chronic lymphocytic leukemia. Am J Cancer Res 2015; 5:2361-2375. [PMID: 26396912 PMCID: PMC4568772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/06/2015] [Indexed: 06/05/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a highly heterogeneous hematologic malignancy and characterized by dysregulation of cell death pathways. Apoptosis and necroptosis are the two major cell death processes, and substantial evidence showed up-regulation of several pro-survival factors in CLL cells. Autophagy, as a dual player in mediating cell death and survival, is largely regarded to be an alternative target in the treatment of CLL. Numerous novel drugs have been developed and are being investigated in clinical trials. It is necessary to depict the impaired cell death pathways in CLL and the pro-survival factors targeted by noncytotoxic drugs directly or indirectly. Here we summarize three dysregulated cell death mechanisms in CLL, and present the current knowledge of drugs that orchestrate cell death via targeting pro-survival factors and the clinical effects as well.
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Affiliation(s)
- Ying Huang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center For Cancer Personalized Medicine, Nanjing Medical University Nanjing 210029, Jiangsu, China
| | - Jia-Zhu Wu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center For Cancer Personalized Medicine, Nanjing Medical University Nanjing 210029, Jiangsu, China
| | - Jian-Yong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center For Cancer Personalized Medicine, Nanjing Medical University Nanjing 210029, Jiangsu, China
| | - Wei Xu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center For Cancer Personalized Medicine, Nanjing Medical University Nanjing 210029, Jiangsu, China
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21
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Zeidner JF, Foster MC, Blackford AL, Litzow MR, Morris LE, Strickland SA, Lancet JE, Bose P, Levy MY, Tibes R, Gojo I, Gocke CD, Rosner GL, Little RF, Wright JJ, Doyle LA, Smith BD, Karp JE. Randomized multicenter phase II study of flavopiridol (alvocidib), cytarabine, and mitoxantrone (FLAM) versus cytarabine/daunorubicin (7+3) in newly diagnosed acute myeloid leukemia. Haematologica 2015; 100:1172-9. [PMID: 26022709 DOI: 10.3324/haematol.2015.125849] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/21/2015] [Indexed: 11/09/2022] Open
Abstract
Serial studies have demonstrated that induction therapy with FLAM [flavopiridol (alvocidib) 50 mg/m(2) days 1-3, cytarabine 667 mg/m(2)/day continuous infusion days 6-8, and mitoxantrone (FLAM) 40 mg/m(2) day 9] yields complete remission rates of nearly 70% in newly diagnosed poor-risk acute myeloid leukemia. Between May 2011-July 2013, 165 newly diagnosed acute myeloid leukemia patients (age 18-70 years) with intermediate/adverse-risk cytogenetics were randomized 2:1 to receive FLAM or 7+3 (cytarabine 100 mg/m(2)/day continuous infusion days 1-7 and daunorubicin 90 mg/m(2) days 1-3), across 10 institutions. Some patients on 7+3 with residual leukemia on day 14 received 5+2 (cytarabine 100 mg/m(2)/day continuous infusion days 1-5 and daunorubicin 45 mg/m(2) days 1-2), whereas patients on FLAM were not re-treated based on day 14 bone marrow findings. The primary objective was to compare complete remission rates between one cycle of FLAM and one cycle of 7+3. Secondary end points included safety, overall survival and event-free survival. FLAM led to higher complete remission rates than 7+3 alone (70% vs. 46%; P=0.003) without an increase in toxicity, and this improvement persisted after 7+3+/-5+2 (70% vs. 57%; P=0.08). There were no significant differences in overall survival and event-free survival in both arms but post-induction strategies were not standardized. These results substantiate the efficacy of FLAM induction in newly diagnosed AML. A phase III study is currently in development. This study is registered with clinicaltrials.gov identifier: 01349972.
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Affiliation(s)
- Joshua F Zeidner
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Matthew C Foster
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Amanda L Blackford
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | - Lawrence E Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Bone Marrow Transplant Group of Georgia, Atlanta, GA, USA
| | | | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Prithviraj Bose
- Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - M Yair Levy
- Texas Oncology, Baylor Charles A. Simmons Cancer Center, Dallas, TX, USA
| | | | - Ivana Gojo
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA University of Maryland Medical Center, Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Christopher D Gocke
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Gary L Rosner
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | | | | | - B Douglas Smith
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Judith E Karp
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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22
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Li L, Pongtornpipat P, Tiutan T, Kendrick SL, Park S, Persky DO, Rimsza LM, Puvvada SD, Schatz JH. Synergistic induction of apoptosis in high-risk DLBCL by BCL2 inhibition with ABT-199 combined with pharmacologic loss of MCL1. Leukemia 2015; 29:1702-12. [PMID: 25882699 PMCID: PMC4526343 DOI: 10.1038/leu.2015.99] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/10/2015] [Accepted: 04/08/2015] [Indexed: 01/13/2023]
Abstract
Better treatments are needed for patients with diffuse large B-cell lymphoma (DLBCL) at high risk of failing standard therapy. Avoiding apoptosis is a hallmark of cancer, and in DLBCL the redundantly functioning anti-apoptotic proteins BCL2 and MCL1 are frequently expressed. Here, we explore drugs that cause loss of MCL1, particularly the potent new cyclin-dependent kinase inhibitor dinaciclib, which knocks down MCL1 by inhibiting CDK9. Dinaciclib induces apoptosis in DLBCL cells but is completely overcome by increased activity of BCL2. We find clinical samples have frequent co-expression of MCL1 and BCL2, suggesting therapeutic strategies targeting only one will lead to treatment failures due to activity of the other. The BH3 mimetic ABT-199 potently and specifically targets BCL2. Single-agent ABT-199 had modest anti-tumor activity against most DLBCL lines and resulted in compensatory up-regulation of MCL1 expression. ABT-199 synergized strongly, however, when combined with dinaciclib and with other drugs affecting MCL1, including standard DLBCL chemotherapy drugs. We show potent anti-tumor activities of these combinations in xenografts and in a genetically accurate murine model of MYC-BCL2 double-hit lymphoma. In sum, we reveal a rational treatment paradigm to strip DLBCL of its protection from apoptosis and improve outcomes for high-risk patients.
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Affiliation(s)
- L Li
- Bio5 Institute, University of Arizona Cancer Center, Tucson, AZ, USA
| | - P Pongtornpipat
- Bio5 Institute, University of Arizona Cancer Center, Tucson, AZ, USA
| | - T Tiutan
- College of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA
| | - S L Kendrick
- Department of Pathology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - S Park
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA
| | - D O Persky
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA
| | - L M Rimsza
- Department of Pathology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - S D Puvvada
- Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA
| | - J H Schatz
- 1] Bio5 Institute, University of Arizona Cancer Center, Tucson, AZ, USA [2] Department of Medicine, University of Arizona Cancer Center, Tucson, AZ, USA [3] Department of Pharmacology and Toxicology, University of Arizona Cancer Center, Tucson, AZ, USA
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23
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Maddocks K, Wei L, Rozewski D, Jiang Y, Zhao Y, Adusumilli M, Pierceall WE, Doykin C, Cardone MH, Jones JA, Flynn J, Andritsos LA, Grever MR, Byrd JC, Johnson AJ, Phelps MA, Blum KA. Reduced occurrence of tumor flare with flavopiridol followed by combined flavopiridol and lenalidomide in patients with relapsed chronic lymphocytic leukemia (CLL). Am J Hematol 2015; 90:327-33. [PMID: 25639448 DOI: 10.1002/ajh.23946] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Abstract
Flavopiridol and lenalidomide have activity in refractory CLL without immunosuppression or opportunistic infections seen with other therapies. We hypothesized that flavopiridol treatment could adequately de-bulk disease prior to lenalidomide therapy, decreasing the incidence of tumor flare with higher doses of lenalidomide. In this Phase I study, the maximum tolerated dose was not reached with treatment consisting of flavopiridol 30 mg m(-2) intravenous bolus (IVB) + 30 mg m(-2) continuous intravenous infusion (CIVI) cycle (C) 1 day (D) 1 and 30 mg m(-2) IVB + 50 mg m(-2) CIVI C1 D8,15 and C2-8 D3,10,17 with lenalidomide 15 mg orally daily C2-8 D1-21. There was no unexpected toxicity seen, including no increased tumor lysis, tumor flare (even at higher doses of lenalidomide) or opportunistic infection. Significant clinical activity was demonstrated, with a 51% response rate in this group of heavily pretreated patients. Biomarker testing confirmed association of mitochondrial priming of the BH3 only peptide Puma with response.
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Affiliation(s)
- Kami Maddocks
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Lai Wei
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Darlene Rozewski
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Yao Jiang
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Yuan Zhao
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Mikhil Adusumilli
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - William E. Pierceall
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Camille Doykin
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Michael H. Cardone
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Jeffrey A. Jones
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Joseph Flynn
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Leslie A. Andritsos
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Michael R. Grever
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - John C. Byrd
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Amy J. Johnson
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Mitch A. Phelps
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Kristie A Blum
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
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24
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Dinaciclib is a novel cyclin-dependent kinase inhibitor with significant clinical activity in relapsed and refractory chronic lymphocytic leukemia. Leukemia 2015; 29:1524-9. [PMID: 25708835 PMCID: PMC4551390 DOI: 10.1038/leu.2015.31] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/08/2014] [Accepted: 12/11/2014] [Indexed: 02/06/2023]
Abstract
Dinaciclib (SCH727965) is a selective CDKi chosen for clinical development based upon a favorable therapeutic index in cancer xenograft models. We performed a phase I dose escalation study of dinaciclib in relapsed and refractory CLL patients with intact organ function and WBC < 200 × 109/L. Five separate dose levels (5 mg/m2, 7 mg/m2, 10 mg/m2, 14 mg/m2, and 17 mg/m2) were explored dosing on a weekly schedule × 3 with one week off (4 week cycles) using a standard 3+3 design with expansion cohorts to optimize safety. Fifty two patients were enrolled with relapsed and refractory CLL. Escalation through cohorts occurred with two DLTs at the 17 mg/m2 dose (TLS and pneumonia). The phase II expansion occurred at 14 mg/m2 with sixteen patients receiving this dose with one DLT (TLS). Additional stepped up dosing to the MTD was examined in 19 patients at this dose. Adverse events included cytopenias, transient laboratory abnormalities, and tumor lysis syndrome. Responses occurred in 28 (54%) of patients independent of del(17)(p13.1) with a median progression free survival of 481 days. Dinaciclib is clinically active in relapsed CLL including those patients with high risk del(17)(p13.1) disease and warrants future study.
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25
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Asghar U, Witkiewicz AK, Turner NC, Knudsen ES. The history and future of targeting cyclin-dependent kinases in cancer therapy. Nat Rev Drug Discov 2015; 14:130-46. [PMID: 25633797 PMCID: PMC4480421 DOI: 10.1038/nrd4504] [Citation(s) in RCA: 1174] [Impact Index Per Article: 130.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cancer represents a pathological manifestation of uncontrolled cell division; therefore, it has long been anticipated that our understanding of the basic principles of cell cycle control would result in effective cancer therapies. In particular, cyclin-dependent kinases (CDKs) that promote transition through the cell cycle were expected to be key therapeutic targets because many tumorigenic events ultimately drive proliferation by impinging on CDK4 or CDK6 complexes in the G1 phase of the cell cycle. Moreover, perturbations in chromosomal stability and aspects of S phase and G2/M control mediated by CDK2 and CDK1 are pivotal tumorigenic events. Translating this knowledge into successful clinical development of CDK inhibitors has historically been challenging, and numerous CDK inhibitors have demonstrated disappointing results in clinical trials. Here, we review the biology of CDKs, the rationale for therapeutically targeting discrete kinase complexes and historical clinical results of CDK inhibitors. We also discuss how CDK inhibitors with high selectivity (particularly for both CDK4 and CDK6), in combination with patient stratification, have resulted in more substantial clinical activity.
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Affiliation(s)
- Uzma Asghar
- Breakthrough Breast Cancer Research Centre, Chester Beatty Laboratories, Institute of Cancer Research, London, SW3 6JB, UK
| | - Agnieszka K Witkiewicz
- Simmons Cancer Center and Department of Pathology, University of Texas Southwestern, Dallas, USA
| | - Nicholas C Turner
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust Breast Cancer Unit, London, SW3 6JJ, UK
| | - Erik S Knudsen
- Simmons Cancer Center and Department of Pathology, University of Texas Southwestern, Dallas, USA
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26
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Nakazawa H, Nishina S, Mimura Y, Kawakami T, Senoo Y, Sakai K, Nakazawa K, Kitano K. Tumor lysis syndrome in a chronic lymphocytic leukemia patient with pleural effusion after oral fludarabine and cyclophosphamide therapy. Int J Hematol 2014; 99:782-5. [DOI: 10.1007/s12185-014-1560-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 02/21/2014] [Accepted: 02/23/2014] [Indexed: 11/29/2022]
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27
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Villicaña C, Cruz G, Zurita M. The basal transcription machinery as a target for cancer therapy. Cancer Cell Int 2014; 14:18. [PMID: 24576043 PMCID: PMC3942515 DOI: 10.1186/1475-2867-14-18] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/21/2014] [Indexed: 01/11/2023] Open
Abstract
General transcription is required for the growth and survival of all living cells. However, tumor cells require extraordinary levels of transcription, including the transcription of ribosomal RNA genes by RNA polymerase I (RNPI) and mRNA by RNA polymerase II (RNPII). In fact, cancer cells have mutations that directly enhance transcription and are frequently required for cancer transformation. For example, the recent discovery that MYC enhances the transcription of the majority genes in the genome correlates with the fact that several transcription interfering drugs preferentially kill cancer cells. In recent years, advances in the mechanistic studies of the basal transcription machinery and the discovery of drugs that interfere with multiple components of transcription are being used to combat cancer. For example, drugs such as triptolide that targets the general transcription factors TFIIH and JQ1 to inhibit BRD4 are administered to target the high proliferative rate of cancer cells. Given the importance of finding new strategies to preferentially sensitize tumor cells, this review primarily focuses on several transcription inhibitory drugs to demonstrate that the basal transcription machinery constitutes a potential target for the design of novel cancer drugs. We highlight the drugs’ mechanisms for interfering with tumor cell survival, their importance in cancer treatment and the challenges of clinical application.
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Affiliation(s)
| | | | - Mario Zurita
- Departament of Developmental Genetics, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Mexico, Mexico.
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28
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Impact of targeted therapy on outcome of chronic lymphocytic leukemia patients with relapsed del(17p13.1) karyotype at a single center. Leukemia 2014; 28:1365-8. [PMID: 24451411 PMCID: PMC4047185 DOI: 10.1038/leu.2014.42] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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29
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Gojo I, Sadowska M, Walker A, Feldman EJ, Iyer SP, Baer MR, Sausville EA, Lapidus RG, Zhang D, Zhu Y, Jou YM, Poon J, Small K, Bannerji R. Clinical and laboratory studies of the novel cyclin-dependent kinase inhibitor dinaciclib (SCH 727965) in acute leukemias. Cancer Chemother Pharmacol 2013; 72:897-908. [PMID: 23949430 PMCID: PMC3784060 DOI: 10.1007/s00280-013-2249-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/26/2013] [Indexed: 01/19/2023]
Abstract
Purpose Dinaciclib inhibits cyclin-dependent kinases 1, 2, 5, and 9 with a better therapeutic index than flavopiridol in preclinical studies. This study assessed the activity of dinaciclib in acute leukemia both in the clinic and in vitro. Methods Adults with relapsed/refractory acute myeloid leukemia (n = 14) and acute lymphoid leukemia (n = 6) were treated with dinaciclib 50 mg/m2 given as a 2-h infusion every 21 days. Results Most patients had dramatic but transient reduction in circulating blasts; however, no remissions were achieved on this schedule. The most common toxicities were gastrointestinal, fatigue, transaminitis, and clinical and laboratory manifestations of tumor lysis syndrome, including one patient who died of acute renal failure. Dinaciclib pharmacokinetics showed rapid (2 h) achievement of maximum concentration and a short elimination/distribution phase. Pharmacodynamic studies demonstrated in vivo inhibition of Mcl-1 expression and induction of PARP cleavage in patients’ peripheral blood mononuclear cells 4 h after dinaciclib infusion, but the effects were lost by 24 h and did not correlate with clinical outcome. Correlative in vitro studies showed that prolonged exposures to dinaciclib, at clinically attainable concentrations, result in improved leukemia cell kill. Conclusions While dinaciclib given as a 2-h bolus did not exhibit durable clinical activity, pharmacokinetic and pharmacodynamic data support the exploration of prolonged infusion schedules in future trials in patients with acute leukemias. Electronic supplementary material The online version of this article (doi:10.1007/s00280-013-2249-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ivana Gojo
- Division of Hematology/Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA,
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Stephens DM, Ruppert AS, Maddocks K, Andritsos L, Baiocchi R, Jones J, Johnson AJ, Smith LL, Zhao Y, Ling Y, Li J, Phelps MA, Grever MR, Byrd JC, Flynn JM. Cyclophosphamide, alvocidib (flavopiridol), and rituximab, a novel feasible chemoimmunotherapy regimen for patients with high-risk chronic lymphocytic leukemia. Leuk Res 2013; 37:1195-9. [PMID: 23867058 DOI: 10.1016/j.leukres.2013.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/22/2013] [Accepted: 06/05/2013] [Indexed: 11/20/2022]
Abstract
Alvocidib has demonstrated efficacy in high-risk chronic lymphocytic leukemia (CLL) patients. In this phase I study, we combined cyclophosphamide, alvocidib and rituximab (CAR) in a schema designed to mitigate tumor lysis syndrome (TLS) seen previously with alvocidib. Nine nucleoside analog-naïve, high-risk patients received escalating doses of CAR therapy. Dose limiting toxicity was not experienced. No instances of TLS were observed. Patient responses included three complete remissions and four partial remissions. CAR was tolerable and active in high-risk CLL patients without TLS toxicity. With continued monitoring of toxicities, a phase Ib/II study of this combination as frontline therapy is warranted.
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Affiliation(s)
- Deborah M Stephens
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, United States.
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Barr PM. Flavopiridol: Judged by the company one keeps. Leuk Res 2013; 37:1187-8. [PMID: 23845889 DOI: 10.1016/j.leukres.2013.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 11/28/2022]
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Ji J, Mould DR, Blum KA, Ruppert AS, Poi M, Zhao Y, Johnson AJ, Byrd JC, Grever MR, Phelps MA. A pharmacokinetic/pharmacodynamic model of tumor lysis syndrome in chronic lymphocytic leukemia patients treated with flavopiridol. Clin Cancer Res 2013; 19:1269-80. [PMID: 23300276 DOI: 10.1158/1078-0432.ccr-12-1092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Flavopiridol, the first clinically evaluated cyclin-dependent kinase inhibitor, shows activity in patients with refractory chronic lymphocytic leukemia, but prevalent and unpredictable tumor lysis syndrome (TLS) presents a major barrier to its broad clinical use. The purpose of this study was to investigate the relationships between pretreatment risk factors, drug pharmacokinetics, and TLS. EXPERIMENTAL DESIGN A population pharmacokinetic/pharmacodynamic model linking drug exposure and TLS was developed. Plasma data of flavopiridol and its glucuronide metabolite (flavo-G) were obtained from 111 patients treated in early-phase trials with frequent sampling following initial and/or escalated doses. TLS grading was modeled with logistic regression as a pharmacodynamic endpoint. Demographics, baseline disease status, and blood chemistry variables were evaluated as covariates. RESULTS Gender was the most significant pharmacokinetic covariate, with females displaying higher flavo-G exposure than males. Glucuronide metabolite exposure was predictive of TLS occurrence, and bulky lymphadenopathy was identified as a significant covariate on TLS probability. The estimated probability of TLS occurrence in patients with baseline bulky lymphadenopathy less than 10 cm or 10 cm or more during the first 2 treatments was 0.111 (SE% 13.0%) and 0.265 (SE% 17.9%), respectively, when flavo-G area under the plasma concentration versus time curve was at its median value in whole-patient group. CONCLUSIONS This is the first population pharmacokinetic/pharmacodynamic model of TLS. Further work is needed to explore potential mechanisms and to determine whether the associations between TLS, gender, and glucuronide metabolites are relevant in patients with chronic lymphocytic leukemia treated with other cyclin-dependent kinase inhibitors.
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Affiliation(s)
- Jia Ji
- The Comprehensive Cancer Center, College of Pharmacy, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio 43210, USA
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Abstract
AKI is common in patients with cancer, and it causes interruptions in therapy and increased hospital length of stay, cost, and mortality. Although cancer patients are susceptible to all of the usual causes of AKI in patients without cancer, there are a number of AKI syndromes that occur more frequently or are unique to this patient population. AKI also confers substantially increased risk of short-term death, and the ability to reverse AKI portends a better outcome in some cancers, such as multiple myeloma. Several trends in oncology, including increased survival, better supportive care, older patients who have received multiple chemotherapy regimens, and new therapeutic options, are driving an increase in the numbers of cancer patients who develop AKI. As a result, nephrologists should be increasingly familiar with the diagnosis, management, and treatment of AKI in this setting. Here, we summarize recent data on epidemiology of AKI in cancer patients, describe the most common AKI syndromes in this population, and highlight emerging areas in the growing field of onconephrology.
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Affiliation(s)
- Albert Q Lam
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Transcription inhibition as a therapeutic target for cancer. Cancers (Basel) 2011; 3:4170-90. [PMID: 24213132 PMCID: PMC3763417 DOI: 10.3390/cancers3044170] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 01/10/2023] Open
Abstract
During tumorigenesis the transformed cells lose their normal growth control mechanisms and become dependent on oncogenes' products and pathways for survival. Treatments tailored to block the expression or function of transforming genes have shown efficacy in eliminating neoplastic cells. The mRNAs of many oncogenes, as well as regulators of other key processes such as cell proliferation, angiogenesis, and apoptosis, typically have shorter half-lives. Agents that impede mRNA synthesis are expected to selectively hinder the expression of these genes and, therefore, be detrimental to neoplastic cells that are physiologically dependent on them. In addition to exploiting the tumor cells' dependency on short-lived transcripts, RNA-directed agents also take advantage of the differential sensitivity between transformed and non-transformed cells, as the cytotoxic effects of inhibiting RNA synthesis have not been seen in non-transformed cells. The abrogation of the formation of oncotranscripts provides a new concept in cancer therapeutics and numerous agents have been developed which are able to target transcription. The focus of this review is to give an overview of transcription and the different inhibitory strategies that target various aspects of the transcriptional process.
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