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Tang K, Lipton JH. Stem cell allografting for chronic Myeloid leukemia in the tyrosine kinase era - forgotten but not gone. Leuk Lymphoma 2024; 65:705-714. [PMID: 38335007 DOI: 10.1080/10428194.2024.2313626] [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: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
Due to the remarkable success of tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML), allogeneic stem cell transplantation (alloSCT) is not first-line treatment for delivering durable, long-term survival. Consequently, alloSCT is reserved for patients with TKI-resistant or TKI-intolerant chronic phase CML (CP-CML) and advanced phase CML (AP-CML). Advances in transplant technology, such as high-resolution HLA typing, introduction of reduced intensity conditioning and increased alternative donor availability, coupled with improved supportive care, have significantly reduced transplant-related mortality and expanded the pool of transplant-eligible patients. Refinement of conditioning regimens, innovative use of post-transplant cellular and pharmacological therapies, and judicious post-transplant monitoring are important strategies for reducing risk of relapse. Given its potential to cure, alloSCT will invariably remain a key part of the treatment algorithm. This article reviews the data underpinning the role and outcomes of alloSCT and provides an update on current recommendations.
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Affiliation(s)
- Kenny Tang
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Haematology, Blacktown Hospital, New South Wales, Australia
| | - Jeffrey H Lipton
- Division of Medical Oncology and Hematology, University Health Network - Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Tousif S, Singh AP, Umbarkar P, Galindo C, Wheeler N, Coro AT, Zhang Q, Prabhu SD, Lal H. Ponatinib Drives Cardiotoxicity by S100A8/A9-NLRP3-IL-1β Mediated Inflammation. Circ Res 2023; 132:267-289. [PMID: 36625265 PMCID: PMC9898181 DOI: 10.1161/circresaha.122.321504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The tyrosine kinase inhibitor ponatinib is the only treatment option for chronic myelogenous leukemia patients with T315I (gatekeeper) mutation. Pharmacovigilance analysis of Food and Drug Administration and World Health Organization datasets has revealed that ponatinib is the most cardiotoxic agent among all Food and Drug Administration-approved tyrosine kinase inhibitors in a real-world scenario. However, the mechanism of ponatinib-induced cardiotoxicity is unknown. METHODS The lack of well-optimized mouse models has hampered the in vivo cardio-oncology studies. Here, we show that cardiovascular comorbidity mouse models evidence a robust cardiac pathological phenotype upon ponatinib treatment. A combination of multiple in vitro and in vivo models was employed to delineate the underlying molecular mechanisms. RESULTS An unbiased RNA sequencing analysis identified the enrichment of dysregulated inflammatory genes, including a multifold upregulation of alarmins S100A8/A9, as a top hit in ponatinib-treated hearts. Mechanistically, we demonstrate that ponatinib activates the S100A8/A9-TLR4 (Toll-like receptor 4)-NLRP3 (NLR family pyrin domain-containing 3)-IL (interleukin)-1β signaling pathway in cardiac and systemic myeloid cells, in vitro and in vivo, thereby leading to excessive myocardial and systemic inflammation. Excessive inflammation was central to the cardiac pathology because interventions with broad-spectrum immunosuppressive glucocorticoid dexamethasone or specific inhibitors of NLRP3 (CY-09) or S100A9 (paquinimod) nearly abolished the ponatinib-induced cardiac dysfunction. CONCLUSIONS Taken together, these findings uncover a novel mechanism of ponatinib-induced cardiac inflammation leading to cardiac dysfunction. From a translational perspective, our results provide critical preclinical data and rationale for a clinical investigation into immunosuppressive interventions for managing ponatinib-induced cardiotoxicity.
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Affiliation(s)
- Sultan Tousif
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
| | - Anand P. Singh
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
| | - Prachi Umbarkar
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
| | - Cristi Galindo
- Department of Biology, Western Kentucky University, Bowling Green, KY 42101, USA35294-1913, USA
| | - Nicholas Wheeler
- Department of Biology, Western Kentucky University, Bowling Green, KY 42101, USA35294-1913, USA
| | - Angelica Toro Coro
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
| | - Qinkun Zhang
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
| | - Sumanth D. Prabhu
- Division of Cardiology, Department of Medicine, Washington University in St. Louis
| | - Hind Lal
- Division of Cardiovascular Disease, UAB | The University of Alabama at Birmingham, Birmingham, AL
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Copland M. Treatment of blast phase chronic myeloid leukaemia: A rare and challenging entity. Br J Haematol 2022; 199:665-678. [PMID: 35866251 PMCID: PMC9796596 DOI: 10.1111/bjh.18370] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/14/2022] [Accepted: 07/07/2022] [Indexed: 01/01/2023]
Abstract
Despite the success of BCR-ABL-specific tyrosine kinase inhibitors (TKIs) such as imatinib in chronic phase (CP) chronic myeloid leukaemia (CML), patients with blast phase (BP)-CML continue to have a dismal outcome with median survival of less than one year from diagnosis. Thus BP-CML remains a critical unmet clinical need in the management of CML. Our understanding of the biology of BP-CML continues to grow; genomic instability leads to acquisition of mutations which drive leukaemic progenitor cells to develop self-renewal properties, resulting in differentiation block and a poor-prognosis acute leukaemia which may be myeloid, lymphoid or bi-phenotypic. Similar advances in therapy are urgently needed to improve patient outcomes; however, this is challenging given the rarity and heterogeneity of BP-CML, leading to difficulty in designing and recruiting to prospective clinical trials. This review will explore the treatment of BP-CML, evaluating the data for TKI therapy alone, combinations with intensive chemotherapy, the role of allogeneic haemopoietic stem cell transplantation, the use of novel agents and clinical trials, as well as discussing the most appropriate methods for diagnosing BP and assessing response to therapy, and factors predicting outcome.
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Affiliation(s)
- Mhairi Copland
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary & Life SciencesInstitute of Cancer Sciences, University of GlasgowGlasgowUK
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Apoptotic and Cell Cycle Effects of Triterpenes Isolated from Phoradendron wattii on Leukemia Cell Lines. Molecules 2022; 27:molecules27175616. [PMID: 36080390 PMCID: PMC9458143 DOI: 10.3390/molecules27175616] [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: 08/08/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Current antineoplastic agents present multiple disadvantages, driving an ongoing search for new and better compounds. Four lupane-type triterpenes, 3α,24-dihydroxylup-20(29)-en-28-oic acid (1), 3α,23-dihydroxy-30-oxo-lup-20(29)-en-28-oic acid (2), 3α,23-O-isopropylidenyl-3α,23-dihydroxylup-20(29)-en-28-oic acid (3), and 3α,23-dihydroxylup-20(29)-en-28-oic acid (4), previously isolated from Phoradendron wattii, were evaluated on two cell lines of chronic (K562) and acute (HL60) myeloid leukemia. Compounds 1, 2, and 4 decreased cell viability and inhibit proliferation, mainly in K562, and exhibited an apoptotic effect from 24 h of treatment. Of particular interest is compound 2, which caused arrest in active phases (G2/M) of the cell cycle, as shown by in silico study of the CDK1/Cyclin B/Csk2 complex by molecular docking. This compound [3α,23-dihydroxy-30-oxo-lup-20(29)-en-28-oic acid] s a promising candidate for incorporation into cancer treatments and deserves further study.
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Aubert L, Petit A, Bertrand Y, Ray-Lunven AF, Angoso M, Pluchart C, Millot F, Saultier P, Cheikh N, Pellier I, Plantaz D, Sirvent A, Thouvenin-Doublet S, Valduga J, Plat G, Rialland F, Henry C, Esvan M, Gandemer V. Therapeutic approach and outcome of children with Philadelphia chromosome-positive acute lymphoblastic leukemia at first relapse in the era of tyrosine kinase inhibitors: An SFCE retrospective study. Pediatr Blood Cancer 2022; 69:e29441. [PMID: 34854546 DOI: 10.1002/pbc.29441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/23/2021] [Accepted: 10/16/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Since the introduction of tyrosine kinase inhibitors (TKIs), the profile of pediatric relapse of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) has changed. However, the management of pediatric Ph+ ALL relapses is not currently standardized. PROCEDURE We retrospectively analyzed the therapeutic strategies and outcomes of pediatric Ph+ ALL patients in first relapse who were initially treated with a TKI-containing regimen in one of the French pediatric hematology centers from 2004 to 2019. RESULTS Twenty-seven children experienced a Ph+ ALL relapse: 24 (89%) had an overt relapse and three a molecular relapse. Eight involved the central nervous system. A second complete remission (CR2) was obtained for 26 patients (96%). Induction consisted of nonintensive chemotherapy for 13 patients (48%) and intensive chemotherapy for 14 (52%). Thirteen patients (48%) received consolidation. Allogenic hematopoietic stem cell transplantation (alloHSCT) was performed for 21 patients (78%). The TKI was changed for 23 patients (88%), mainly with dasatinib (n = 15). T315I was the most common mutation at relapse (4/7). The 4-year event-free survival and survival rates were 60.9% and 76.1%, respectively. Survival was positively associated with alloHSCT in CR2. CONCLUSION We show that pediatric first-relapse Ph+ ALL reinduces well with a second course of TKI exposure, despite the use of different therapeutic approaches. The main prognostic factor for survival was alloHSCT in CR2. Because of the small size of the cohort, we could not draw any conclusions about the respective impact of TKIs, but the predominance of the T315I mutation should encourage careful consideration of the TKI choice.
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Affiliation(s)
- Lucie Aubert
- Department of Pediatric Hemato-Oncology, University Hospital of Rennes, Rennes, France
| | - Arnaud Petit
- Pediatric Hematology and Oncology Department, Armand Trousseau Hospital, APHP, Paris, France
| | - Yves Bertrand
- Department of the Institute of Pediatric Hematology and Oncology, University Hospital of Lyon, Lyon, France
| | | | - Marie Angoso
- Pediatric Hematology Oncology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Claire Pluchart
- Department of Pediatric Onco-Hematology, University Hospital of Reims, Reims, France
| | - Frédéric Millot
- Department of Hematological Oncology and Cell Therapy, University Hospital of Poitiers, Poitiers, France
| | - Paul Saultier
- Pediatric Hematology and Oncology Department, La Timone Children's Hospital, AP-HM, Marseille, France
| | - Nathalie Cheikh
- Pediatric Hematology Oncology Unity, University Hospital of Besançon, Besançon, France
| | - Isabelle Pellier
- Pediatric Hematology and Oncology Immunology Department, University Hospital of Angers, Angers, France
| | - Dominique Plantaz
- Pediatric Immuno-Hemato-Oncology Department, University Hospital of Grenoble, Grenoble, France
| | - Anne Sirvent
- Department of Pediatric Onco-Hematology, University Hospital of Montpellier, Montpellier, France
| | | | - Julie Valduga
- Pediatric Oncology and Hematology Department, University Hospital of Nancy (CHRU Nancy), Nancy, France
| | - Geneviève Plat
- Department of Pediatric Hemato-Oncology, University Hospital of Toulouse, Toulouse, France
| | - Fanny Rialland
- Department of Pediatric Onco-Hematology, University Hospital of Nantes, Nantes, France
| | - Catherine Henry
- Cytogenetic and Cell Biology Department, University Hospital of Rennes, Rennes, France
| | - Maxime Esvan
- Rennes University, University Hospital of Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
| | - Virginie Gandemer
- Department of Pediatric Hemato-Oncology, University Hospital of Rennes, Rennes, France
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Copland M, Slade D, McIlroy G, Horne G, Byrne JL, Rothwell K, Brock K, De Lavallade H, Craddock C, Clark RE, Smith ML, Fletcher R, Bishop R, Milojkovic D, Yap C. Ponatinib with fludarabine, cytarabine, idarubicin, and granulocyte colony-stimulating factor chemotherapy for patients with blast-phase chronic myeloid leukaemia (MATCHPOINT): a single-arm, multicentre, phase 1/2 trial. Lancet Haematol 2022; 9:e121-e132. [PMID: 34906334 DOI: 10.1016/s2352-3026(21)00370-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Outcomes for patients with blast-phase chronic myeloid leukaemia are poor. Long-term survival depends on reaching a second chronic phase, followed by allogeneic haematopoietic stem-cell transplantation (HSCT). We investigated whether the novel combination of the tyrosine-kinase inhibitor ponatinib with fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin (FLAG-IDA) could improve response and optimise allogeneic HSCT outcomes in patients with blast-phase chronic myeloid leukaemia. The aim was to identify a dose of ponatinib, which combined with FLAG-IDA, showed clinically meaningful activity and tolerability. METHODS MATCHPOINT was a seamless, phase 1/2, multicentre trial done in eight UK Trials Acceleration Programme-funded centres. Eligible participants were adults (aged ≥16 years) with Philadelphia chromosome-positive or BCR-ABL1-positive blast-phase chronic myeloid leukaemia, suitable for intensive chemotherapy. Participants received up to two cycles of ponatinib with FLAG-IDA. Experimental doses of oral ponatinib (given from day 1 to day 28 of FLAG-IDA) were between 15 mg alternate days and 45 mg once daily and the starting dose was 30 mg once daily. Intravenous fludarabine (30 mg/m2 for 5 days), cytarabine (2 g/m2 for 5 days), and idarubicin (8 mg/m2 for 3 days), and subcutaneous granulocyte colony-stimulating factor (if used), were delivered according to local protocols. We used an innovative EffTox design to investigate the activity and tolerability of ponatinib-FLAG-IDA; the primary endpoints were the optimal ponatinib dose meeting prespecified thresholds of activity (inducement of second chronic phase defined as either haematological or minor cytogenetic response) and tolerability (dose-limiting toxicties). Analyses were planned on an intention-to-treat basis. MATCHPOINT was registered as an International Standard Randomised Controlled Trial, ISRCTN98986889, and has completed recruitment; the final results are presented. FINDINGS Between March 19, 2015, and April 26, 2018, 17 patients (12 men, five women) were recruited, 16 of whom were evaluable for the coprimary outcomes. Median follow-up was 41 months (IQR 36-48). The EffTox model simultaneously considered clinical responses and dose-limiting toxicities, and determined the optimal ponatinib dose as 30 mg daily, combined with FLAG-IDA. 11 (69%) of 16 patients were in the second chronic phase after one cycle of treatment. Four (25%) patients had a dose-limiting toxicity (comprising cardiomyopathy and grade 4 increased alanine aminotransferase, cerebral venous sinus thrombosis, grade 3 increased amylase, and grade 4 increased alanine aminotransferase), fulfilling the criteria for clinically relevant activity and toxicity. 12 (71%) of 17 patients proceeded to allogeneic HSCT. The most common grade 3-4 non-haematological adverse events were lung infection (n=4 [24%]), fever (n=3 [18%]), and hypocalcaemia (n=3 [18%]). There were 12 serious adverse events in 11 (65%) patients. Three (18%) patients died due to treatment-related events (due to cardiomyopathy, pulmonary haemorrhage, and bone marrow aplasia). INTERPRETATION Ponatinib-FLAG-IDA can induce second chronic phase in patients with blast-phase chronic myeloid leukaemia, representing an active salvage therapy to bridge to allogeneic HSCT. The number of treatment-related deaths is not in excess of what would be expected in this very high-risk group of patients receiving intensive chemotherapy. The efficient EffTox method is a model for investigating novel therapies in ultra-orphan cancers. FUNDING Blood Cancer UK and Incyte.
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Affiliation(s)
- Mhairi Copland
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Gartnavel General Hospital, Glasgow, UK.
| | - Daniel Slade
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Graham McIlroy
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gillian Horne
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Gartnavel General Hospital, Glasgow, UK
| | - Jenny L Byrne
- Department of Clinical Haematology, Nottingham University Hospitals, Nottingham, UK
| | - Kate Rothwell
- Department of Clinical Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Richard E Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Matthew L Smith
- Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK
| | - Rachel Fletcher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca Bishop
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK; Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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Ganesan P, Kayal S. How I Treat Adult Acute Lymphoblastic Leukemia in India. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1731979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Prasanth Ganesan
- Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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Balsat M, Cacheux V, Carre M, Tavernier-Tardy E, Thomas X. Treatment and outcome of Philadelphia chromosome-positive acute lymphoblastic leukemia in adults after relapse. Expert Rev Anticancer Ther 2020; 20:879-891. [PMID: 33016157 DOI: 10.1080/14737140.2020.1832890] [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: 10/23/2022]
Abstract
INTRODUCTION Despite the significant progress that has been made over the last years in the front-line treatment of Philadelphia (Ph) chromosome-positive acute lymphoblastic leukemia (ALL), relapses are frequent and their treatment remains a challenge, especially among patients with resistant BCR-ABL1 mutations. AREAS COVERED This manuscript reviews available data for the treatment of adult patients with relapsed/refractory Ph-positive ALL, with a focus on the role of tyrosine kinase inhibitors (TKIs), monoclonal antibodies, and immunotherapy. EXPERT OPINION Although a majority of patients with first relapsed Ph-positive ALL respond to subsequent salvage chemotherapy plus TKI combination, their outcomes remain poor. The main predictor of survival is the achievement of major molecular response anytime during the morphological response. More treatment strategies to improve survival are under investigation. Monoclonal antibodies and bispecific antibody constructs hold considerable promise in improving the outcomes of patients with relapsed ALL including Ph-positive ALL.
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Affiliation(s)
- Marie Balsat
- Hospices Civils de Lyon, Service d'Hématologie Clinique, Centre Hospitalier Lyon-Sud , Pierre-Bénite, France
| | - Victoria Cacheux
- Service de Thérapie Cellulaire et Hématologie Clinique, Centre Hospitalier Universitaire , Clermont-Ferrand, France
| | - Martin Carre
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire Grenoble Alpes , Grenoble, France
| | - Emmanuelle Tavernier-Tardy
- Service d'Hématologie Clinique, Institut de Cancérologie de la Loire Lucien Neuwirth , Saint-Etienne, France
| | - Xavier Thomas
- Hospices Civils de Lyon, Service d'Hématologie Clinique, Centre Hospitalier Lyon-Sud , Pierre-Bénite, France
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10
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Bonifacio M, Stagno F, Scaffidi L, Krampera M, Di Raimondo F. Management of Chronic Myeloid Leukemia in Advanced Phase. Front Oncol 2019; 9:1132. [PMID: 31709190 PMCID: PMC6823861 DOI: 10.3389/fonc.2019.01132] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Management of chronic myeloid leukemia (CML) in advanced phases remains a challenge also in the era of tyrosine kinase inhibitors (TKIs) treatment. Cytogenetic clonal evolution and development of resistant mutations represent crucial events that limit the benefit of subsequent therapies in these patients. CML is diagnosed in accelerated (AP) or blast phase (BP) in <5% of patients, and the availability of effective treatments for chronic phase (CP) has dramatically reduced progressions on therapy. Due to smaller number of patients, few randomized studies are available in this setting and evidences are limited. Nevertheless, three main scenarios may be drawn: (a) patients diagnosed in AP are at higher risk of failure as compared to CP patients, but if they achieve optimal responses with frontline TKI treatment their outcome may be similarly favorable; (b) patients diagnosed in BP may be treated with TKI alone or with TKI together with conventional chemotherapy regimens, and subsequent transplant decisions should rely on kinetics of response and individual transplant risk; (c) patients in CP progressing under TKI treatment represent the most challenging population and they should be treated with alternative TKI according to the mutational profile, optional chemotherapy in BP patients, and transplant should be considered in suitable cases after return to second CP. Due to lack of validated and reliable markers to predict blast crisis and the still unsatisfactory results of treatments in this setting, prevention of progression by careful selection of frontline treatment in CP and early treatment intensification in non-optimal responders remains the main goal. Personalized evaluation of response kinetics could help in identifying patients at risk for progression.
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Affiliation(s)
| | - Fabio Stagno
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Francesco Di Raimondo
- Division of Hematology With BMT, AOU Policlinico “Vittorio Emanuele”, University of Catania, Catania, Italy
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Ma Y, Zhang Q, Kong P, Xiong J, Zhang X, Zhang C. Treatment Selection for Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia in the Era of Tyrosine Kinase Inhibitors. Chemotherapy 2019; 64:81-93. [PMID: 31390613 DOI: 10.1159/000501061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/18/2019] [Indexed: 12/20/2022]
Abstract
With the advent of tyrosine kinase inhibitors (TKIs), the treatment of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) has entered a new era. The efficacy of TKIs compared with other ALL treatment options is emphasized by a rapid increase in the number of TKI clinical trials. Subsequently, the use of traditional approaches, such as combined chemotherapy and even allogeneic hematopoietic stem cell transplantation (allo-HSCT), for the treatment of ALL is being challenged in the clinic. In light of the increased use of TKIs in the clinic, several questions have been raised. First, is it necessary to use intensive chemotherapy during the induction course of therapy to achieve a minimal residual disease (MRD)-negative status? Must a patient reach a complete molecular response/major molecular response before receiving allo-HSCT? Does MRD status affect long-term survival after allo-HSCT? Is auto-HSCT an appropriate alternative for allo-HSCT in those Ph+ ALL patients who lack suitable donors? Here, we review the recent literature in an attempt to summarize the current status of TKI usage in the clinic, including several new therapeutic approaches, provide answers for the above questions, and speculate on the future direction of TKI utilization for the treatment of Ph+ ALL patients.
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Affiliation(s)
- Yingying Ma
- Hematology Department, State Key Laboratory of Trauma, Burns and Combined Injury, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Quanchao Zhang
- Shigatse Branch, Xinqiao Hospital, Army Medical University (Third Military Medical University), Shigatse, China
| | - Peiyan Kong
- Hematology Department, State Key Laboratory of Trauma, Burns and Combined Injury, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Jingkang Xiong
- Hematology Department, State Key Laboratory of Trauma, Burns and Combined Injury, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xi Zhang
- Hematology Department, State Key Laboratory of Trauma, Burns and Combined Injury, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Cheng Zhang
- Hematology Department, State Key Laboratory of Trauma, Burns and Combined Injury, Xinqiao Hospital of Army Medical University, Chongqing, China,
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12
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Nee A, Lipton JH. Update on the management of chronic myeloid leukemia: current best practice and future directions. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1609939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Aisling Nee
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey H. Lipton
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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13
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Craddock CF. We do still transplant CML, don't we? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:177-184. [PMID: 30504307 PMCID: PMC6246013 DOI: 10.1182/asheducation-2018.1.177] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The remarkable clinical activity of tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML) has transformed patient outcome. Consequently, allogeneic stem cell transplantation (allo-SCT) is no longer the only treatment modality with the ability to deliver long-term survival. In contrast to the central position it held in the treatment algorithm 20 years ago, allografting is now largely reserved for patients with either chronic-phase disease resistant to TKI therapy or advanced-phase disease. Over the same period, progress in transplant technology, principally the introduction of reduced intensity conditioning regimens coupled with increased donor availability, has extended transplant options in patients with CML whose outcome can be predicted to be poor if they are treated with TKIs alone. Consequently, transplantation is still a vitally important, potentially curative therapeutic modality in selected patients with either chronic- or advanced-phase CML. The major causes of transplant failure in patients allografted for CML are transplant toxicity and disease relapse. A greater understanding of the distinct contributions made by various factors such as patient fitness, patient-donor HLA disparity, conditioning regimen intensity, and transplant toxicity increasingly permits personalized transplant decision making. At the same time, advances in the design of conditioning regimens coupled with the use of adjunctive posttransplant cellular and pharmacologic therapies provide opportunities for reducing the risk of disease relapse. The role of SCT in the management of CML will grow in the future because of an increase in disease prevalence and because of continued improvements in transplant outcome.
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Affiliation(s)
- Charles F Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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El Fakih R, Jabbour E, Ravandi F, Hassanein M, Anjum F, Ahmed S, Kantarjian H. Current paradigms in the management of Philadelphia chromosome positive acute lymphoblastic leukemia in adults. Am J Hematol 2018; 93:286-295. [PMID: 28971501 DOI: 10.1002/ajh.24926] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 02/03/2023]
Abstract
Philadelphia chromosome-positive (Ph-positive) acute lymphoblastic leukemia (ALL) is a biologically, clinically, and genetically distinct subtype of precursor-B ALL. The Ph chromosome, results from a reciprocal translocation of the ABL1 kinase gene on chromosome 9 to the breakpoint cluster region (BCR) gene on chromosome 22. Depending on the translocation breakpoint, typically a p210 BCR-ABL1 or a p190 BCR-ABL onc protein are generated; both are constitutively active tyrosine kinases that play a central role to alter signaling pathways of cell proliferation, survival, and self-renewal, leading to leukemogenesis. In Ph-positive ALL, the p190-BCR-ABL (minor [m]-bcr) subtype is more frequent than the p210-BCR-ABL (major [M]-bcr) subtype, commonly found in chronic myeloid leukemia. The Philadelphia chromosome is the most frequent recurrent cytogenetic abnormality in elderly patients with ALL. Its incidence increases with age, reaching ∼50% in patients with ALL aged 60 years and over. Patients traditionally had a very poor outcome with chemotherapy, particularly if they do not undergo allogeneic hematopoietic cell transplantation (allo-HCT) in first complete remission (CR1). With the availability of multiple tyrosine kinase inhibitors (TKI), the therapeutic armamentarium is expanding quickly. However, there is no consensus on how to best treat Ph-positive ALL. With modern therapy, improved outcomes have led to the emergence of a number of controversies, including the need for intensive chemotherapy, the ideal TKI, and whether all eligible patients should receive an allo-HSCT, and if so, what type. Here, we discuss these controversies in light of the available literature.
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Affiliation(s)
- Riad El Fakih
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Elias Jabbour
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Mona Hassanein
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Farhan Anjum
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Syed Ahmed
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Hagop Kantarjian
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
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15
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Hehlmann R, Saußele S, Voskanyan A, Silver RT. Management of CML-blast crisis. Best Pract Res Clin Haematol 2016; 29:295-307. [PMID: 27839570 DOI: 10.1016/j.beha.2016.10.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/10/2016] [Indexed: 12/28/2022]
Abstract
Tyrosine kinase inhibitors (TKI) have moderately improved survival in BC, but a median survival of less than 1 year is still unsatisfactory. This article reviews the various tests required for diagnosis of BC, features at diagnosis, treatment modalities (intensive chemotherapy, TKI, allo-SCT and a selection of investigational agents), options of prevention and predictors of progression. The best prognosis is observed in patients that achieve a 2nd CP. Allo-SCT probably further improves prognosis of patients in 2nd CP. The choice of TKI should be directed by the mutation profile of the patient. BC can be prevented. A careful analysis of risk factors for progression may help. Current treatment options are combined in a concluding strategy for the management of BC.
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Affiliation(s)
- Rüdiger Hehlmann
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Susanne Saußele
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Astghik Voskanyan
- Medizinische Fakultät Mannheim, Universität Heidelberg, III. Medizinische Klinik, Pettenkoferstr. 22, 68169 Mannheim, Germany.
| | - Richard T Silver
- Division of Hematology/Medical Oncology, Weill Cornell Medical College, New York, NY, USA.
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16
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Hossain A, Gupta K, Mener A, Tabbara I. Case of CML lymphoid blast crisis presenting as bilateral breast masses. BMJ Case Rep 2016; 2016:bcr-2016-215825. [PMID: 27511749 DOI: 10.1136/bcr-2016-215825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman aged 42 years with a 1-month history of rapidly expanding bilateral breast masses presented with severe leucocytosis, anaemia, blurry vision, headaches and shortness of breath. Evaluation revealed chronic myeloid leukaemia in lymphoid blast crisis with extramedullary leukaemia involving her breasts.
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Affiliation(s)
- Aneesha Hossain
- Department of Internal Medicine, George Washington University Hospital, Washington, District of Columbia, USA
| | - Kanika Gupta
- Department of Internal Medicine, George Washington University Hospital, Washington, District of Columbia, USA
| | - Andrew Mener
- Department of Hematology/Oncology, The George Washington University, Washington, District of Columbia, USA
| | - Imad Tabbara
- Department of Hematology/Oncology, The George Washington University, Washington, District of Columbia, USA
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17
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Perrone S, Massaro F, Alimena G, Breccia M. How has treatment changed for blast phase chronic myeloid leukemia patients in the tyrosine kinase inhibitor era? A review of efficacy and safety. Expert Opin Pharmacother 2016; 17:1517-26. [DOI: 10.1080/14656566.2016.1190335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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18
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Dasatinib and low-intensity chemotherapy in elderly patients with Philadelphia chromosome-positive ALL. Blood 2016; 128:774-82. [PMID: 27121472 DOI: 10.1182/blood-2016-02-700153] [Citation(s) in RCA: 203] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 04/13/2016] [Indexed: 12/27/2022] Open
Abstract
Prognosis of Philadelphia-positive (Ph(+)) acute lymphoblastic leukemia (ALL) in the elderly has improved during the imatinib era. We investigated dasatinib, another potent tyrosine kinase inhibitor, in combination with low-intensity chemotherapy. Patients older than age 55 years were included in the European Working Group on Adult ALL (EWALL) study number 01 for Ph(+) ALL (EWALL-PH-01 international study) and were treated with dasatinib 140 mg/day (100 mg/day over 70 years) with intrathecal chemotherapy, vincristine, and dexamethasone during induction. Patients in complete remission continued consolidation with dasatinib, sequentially with cytarabine, asparaginase, and methotrexate for 6 months. Maintenance therapy was dasatinib and vincristine/dexamethasone reinductions for 18 months followed by dasatinib until relapse or death. Seventy-one patients with a median age of 69 years were enrolled; 77% had a high comorbidity score. Complete remission rate was 96% and 65% of patients achieved a 3-log reduction in BCR-ABL1 transcript levels during consolidation. Only 7 patients underwent allogeneic hematopoietic stem cell transplantation. At 5 years, overall survival was 36% and up to 45% taking into account deaths unrelated to disease or treatment as competitors. Thirty-six patients relapsed, 24 were tested for mutation by Sanger sequencing, and 75% were T315I-positive. BCR-ABL1(T315I) was tested by allele-specific oligonucleotide reverse transcription-quantitative polymerase chain reaction in 43 patients and detection was associated with short-term relapses. Ten patients (23%) were positive before any therapy and 8 relapsed, all with this mutation. In conclusion, dasatinib combined with low-intensity chemotherapy was well-tolerated and gave long-term survival in 36% of elderly patients with Ph(+) ALL. Monitoring of BCR-ABL1(T315I) from diagnosis identified patients with at high risk of early relapse and may help to personalize therapy.
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19
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Management of Elderly Patients with Newly Diagnosed Chronic Myeloid Leukemia in the Accelerated or Blastic Phase. Drugs Aging 2016; 33:335-45. [PMID: 26961697 DOI: 10.1007/s40266-016-0351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the elderly population, the accelerated and blastic phases of chronic myeloid leukemia (CML) are difficult to treat, not just because of the higher chance of acquired mutations than in younger individuals, but because of additional associated co-morbidities. Tyrosine kinase inhibitors are well-established in the treatment of the chronic phase of CML, and their use in advanced phases is ever-increasing. Elderly patients who are still eligible candidates for transplant can undergo reduced-intensity transplants from related or unrelated donors after reverting to chronic phase. Post-transplantation, these patients require adequate monitoring and therapy to prevent relapses. Newer modalities of treatment or interventions are urgently required in this complex group of patients.
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20
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Saußele S, Silver RT. Management of chronic myeloid leukemia in blast crisis. Ann Hematol 2015; 94 Suppl 2:S159-65. [PMID: 25814082 DOI: 10.1007/s00277-015-2324-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/07/2014] [Indexed: 12/15/2022]
Abstract
Due to the high efficacy of BCR-ABL tyrosine kinase inhibition (TKI) in chronic phase (CP) chronic myeloid leukemia (CML), the frequency of blast crisis (BC) is greatly reduced compared to the pre-TKI era. However, TKI treatment of BC has only marginally improved the number of favorable responses, including remissions, which for the most part have only been transitory. Occasionally, they provide a therapeutic window to perform an allogeneic stem cell transplantation (allo-SCT). The challenge remains to improve management of BC with the limited options available. We review and summarize articles pertaining to the treatment of BC CML published after 2002. Additionally, we will discuss whether there is a need for a new definition of BC and/or treatment failure.
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Affiliation(s)
- S Saußele
- III. Medizinische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Pettenkoferstr. 22, 68169, Mannheim, Germany,
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21
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Ojeda-Uribe M, Merieau S, Guillon M, Aujoulat O, Hinschberger O, Eisenmann JC, Kenizou D, Debliquis A, Veyradier A, Chantrel F. Secondary thrombotic microangiopathy in two patients with Philadelphia-positive hematological malignancies treated with imatinib mesylate. J Oncol Pharm Pract 2015; 22:361-70. [PMID: 25591869 DOI: 10.1177/1078155214568580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Drug-mediated thrombotic microangiopathy may cause life-threatening medical emergencies. Novel targeted therapies have dramatically changed the prognosis of a number of oncological diseases. Tyrosine kinase inhibitors of the Breakpoint Cluster Region-Abelson (BCR-ABL) oncoprotein are used in patients with chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphoblastic leukemia. Imatinib mesylate, which was the first anti-BCR-ABL tyrosine kinase inhibitor, has demonstrated a high tolerance profile and efficacy in these patients for many years. Good results have also been observed in patients with gastrointestinal stromal tumors. In this study, we describe two patients with Philadelphia chromosome-positive hematological malignancies who presented with secondary thrombotic microangiopathy that was most likely linked to the use of imatinib. Other potential causes of thrombotic microangiopathy were discarded, and the predisposing role of some comorbidities and potential short or long-term drug-drug interactions was assessed. The clinical and biological data were more indicative of atypical secondary hemolytic uremic syndrome in one of the cases and of secondary thrombotic microangiopathy with renal and cardiac impairment in the other, which is also categorized as secondary hemolytic uremic syndrome. The outcome was favorable after imatinib discontinuation and the treatment of severe cardiac and renal failures.
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Affiliation(s)
- Mario Ojeda-Uribe
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France
| | - Sylvain Merieau
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Marie Guillon
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | | | - Olivier Hinschberger
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Internal Medicine, Hôpital Emile Muller, Mulhouse, France
| | - Jean-Claude Eisenmann
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France
| | - David Kenizou
- Department of Cardiology, Hôpital Emile Muller, Mulhouse, France
| | - Agathe Debliquis
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Agnès Veyradier
- Department of Biological Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Université Paris, Clamart, France
| | - François Chantrel
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Nephrology, Hôpital Emile Muller, Mulhouse, France
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22
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Brissot E, Labopin M, Beckers MM, Socié G, Rambaldi A, Volin L, Finke J, Lenhoff S, Kröger N, Ossenkoppele GJ, Craddock CF, Yakoub-Agha I, Gürman G, Russell NH, Aljurf M, Potter MN, Nagler A, Ottmann O, Cornelissen JJ, Esteve J, Mohty M. Tyrosine kinase inhibitors improve long-term outcome of allogeneic hematopoietic stem cell transplantation for adult patients with Philadelphia chromosome positive acute lymphoblastic leukemia. Haematologica 2014; 100:392-9. [PMID: 25527562 DOI: 10.3324/haematol.2014.116954] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study aimed to determine the impact of tyrosine kinase inhibitors given pre- and post-allogeneic stem cell transplantation on long-term outcome of patients allografted for Philadelphia chromosome-positive acute lymphoblastic leukemia. This retrospective analysis from the EBMT Acute Leukemia Working Party included 473 de novo Philadelphia chromosome-positive acute lymphoblastic leukemia patients in first complete remission who underwent an allogeneic stem cell transplantation using a human leukocyte antigen-identical sibling or human leukocyte antigen-matched unrelated donor between 2000 and 2010. Three hundred and ninety patients received tyrosine kinase inhibitors before transplant, 329 at induction and 274 at consolidation. Kaplan-Meier estimates of leukemia-free survival, overall survival, cumulative incidences of relapse incidence, and non-relapse mortality at five years were 38%, 46%, 36% and 26%, respectively. In multivariate analysis, tyrosine-kinase inhibitors given before allogeneic stem cell transplantation was associated with a better overall survival (HR=0.68; P=0.04) and was associated with lower relapse incidence (HR=0.5; P=0.01). In the post-transplant period, multivariate analysis identified prophylactic tyrosine-kinase inhibitor administration to be a significant factor for improved leukemia-free survival (HR=0.44; P=0.002) and overall survival (HR=0.42; P=0.004), and a lower relapse incidence (HR=0.40; P=0.01). Over the past decade, administration of tyrosine kinase inhibitors before allogeneic stem cell transplantation has significantly improved the long-term allogeneic stem cell transplantation outcome of adult Philadelphia chromosome-positive acute lymphoblastic leukemia. Prospective studies will be of great interest to further confirm the potential benefit of the prophylactic use of tyrosine kinase inhibitors in the post-transplant setting.
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Affiliation(s)
- Eolia Brissot
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France CHRU Hôtel-Dieu, Nantes, France
| | - Myriam Labopin
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France
| | | | | | | | - Liisa Volin
- Helsinki University Central Hospital, Finland
| | | | | | | | | | | | | | - Günhan Gürman
- Ankara University, Faculty of Medicine, Ankara, Turkey
| | | | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | | | | - Jan J Cornelissen
- Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
| | - Jordi Esteve
- Hospital Clinic Institut d'investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Mohamad Mohty
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France
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23
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Couban S, Savoie L, Mourad YA, Leber B, Minden M, Turner R, Palada V, Shehata N, Christofides A, Lachance S. Evidence-based guidelines for the use of tyrosine kinase inhibitors in adults with Philadelphia chromosome-positive or BCR-ABL-positive acute lymphoblastic leukemia: a Canadian consensus. ACTA ACUST UNITED AC 2014; 21:e265-309. [PMID: 24764712 DOI: 10.3747/co.21.1834] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Adult Philadelphia chromosome-positive (Ph+) or BCR-ABL-positive (BCR-ABL+) acute lymphoblastic leukemia (all) is an acute leukemia previously associated with a high relapse rate, short disease-free survival, and poor overall survival. In adults, allogeneic hematopoietic cell transplant in first remission remains the only proven curative strategy for transplant-eligible patients. The introduction of tyrosine kinase inhibitors (tkis) in the treatment of patients with Ph+ or BCR-ABL+ all has significantly improved the depth and duration of complete remission, allowing more patients to proceed to transplantation. Although tkis are now considered a standard of care in this setting, few randomized trials have examined the optimal use of tkis in patients with Ph+ all. Questions of major importance remain, including the best way to administer these medications, the choice of tki to administer, and the schedule and the duration to use. We present the results of a systematic review of the literature with consensus recommendations based on the available evidence.
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Affiliation(s)
- S Couban
- Department of Medicine, Dalhousie University, Halifax, NS
| | - L Savoie
- University of Calgary, Calgary, AB
| | - Y Abou Mourad
- Leukemia and Bone Marrow Transplant Program of British Columbia, University of British Columbia, Vancouver, BC
| | - B Leber
- McMaster University, Hamilton, ON
| | - M Minden
- Department of Medical Oncology, University Health Network, University of Toronto, Toronto, ON
| | - R Turner
- Cross Cancer Institute, Edmonton, AB
| | - V Palada
- University of Toronto, St Michael's Hospital, Toronto, ON
| | - N Shehata
- University of Toronto, St Michael's Hospital, Toronto, ON
| | | | - S Lachance
- Hospital Maisonneuve-Rosemont, University of Montreal, Montreal, QC
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24
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Maino E, Sancetta R, Viero P, Imbergamo S, Scattolin AM, Vespignani M, Bassan R. Current and future management of Ph/BCR-ABL positive ALL. Expert Rev Anticancer Ther 2014; 14:723-40. [PMID: 24611626 DOI: 10.1586/14737140.2014.895669] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Following the introduction of targeted therapy with tyrosine kinase inhibitors (TKI) at the beginning of the past decade, the outcome of patients with Philadelphia-chromosome positive acute lymphoblastic leukemia (Ph+ ALL) has dramatically improved. Presently, the use of refined programs with first/second generation TKI's and chemotherapy together with allogeneic stem cell transplantation allow up to 50% of all patients to be cured. Further progress is expected with the new TKI ponatinib, overcoming resistance caused by T315I point mutation, other targeted therapies, autologous transplantation in molecularly negative patients, therapeutic monoclonal antibodies like inotuzumab ozogamicin and blinatumomab, and chimeric antigen receptor-modified T cells. Ph+ ALL could become curable in the near future even without allogeneic stem cell transplantation, minimizing the risk of therapy-related death and improving greatly the quality of patients' life.
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Affiliation(s)
- Elena Maino
- Hematology/Bone Marrow Transplantation Unit, Ospedale dell'Angelo and Ospedale SS. Giovanni e Paolo, Via Paccagnella 11, 30174 Venezia-Mestre, Italy
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25
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Randomized comparison of prophylactic and minimal residual disease-triggered imatinib after allogeneic stem cell transplantation for BCR-ABL1-positive acute lymphoblastic leukemia. Leukemia 2012; 27:1254-62. [PMID: 23212150 DOI: 10.1038/leu.2012.352] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Minimal residual disease (MRD) after allogeneic stem cell transplantation (SCT) for Ph+ acute lymphoblastic leukemia (ALL) is predictive of relapse. Imatinib administration subsequent to SCT may prevent relapse, but the role of scheduling and its impact on outcome are not known. In a prospective, randomized multicenter trial, we compared the tolerability and efficacy of post-transplant imatinib administered either prophylactically (arm A; n=26) or following detection of MRD (arm B; n=29). Prophylactic imatinib significantly reduced the incidence of molecular recurrence after SCT compared with MRD-triggered imatinib (40% vs 69%; P=0.046). Median duration of PCR negativity was 26.5 and 6.8 months, respectively (P=0.065). Five-year survival in both interventional groups was high (80 and 74.5%), despite premature discontinuation of imatinib in the majority of patients because of poor tolerability. Relapse probability was significantly higher in patients who became MRD positive (P=0.017). In conclusion, post-transplant imatinib results in a low relapse rate, durable remissions and excellent long-term outcome in patients with BCR-ABL1-positive ALL irrespective of whether it is given prophylactically or MRD-triggered. Reappearance of BCR-ABL1 transcripts early after SCT or at higher levels identifies a small subset of patients who do not benefit sufficiently from imatinib, and in whom alternative approaches should be explored.
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26
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Breccia M, Serrao A, Salaroli A, Loglisci G, Zacheo I, Alimena G. Dasatinib combined with weekly administration of vincristine as effective therapy in sudden or resistant Ph+ lymphoid blast crisis of chronic myeloid leukaemia. Br J Haematol 2012; 159:612-3. [PMID: 23043319 DOI: 10.1111/bjh.12079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Abstract
Tyrosine kinase inhibitors (TKIs) directed against the ABL kinase are now used routinely during frontline therapy for Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) and result in hematologic remission rates exceeding 90%. Minimal residual disease levels are generally lower when TKIs are used in combination with chemotherapy rather than as monotherapy. Although outcome has improved substantially with TKI-based regimens compared with historic controls, allogeneic stem cell transplantation (SCT) in first remission provides the best chance of cure for the majority of patients eligible for SCT. Administration of imatinib after SCT further reduces molecular recurrence and is associated with greatly improved relapse-free and overall survival. The high relapse rate in non-transplanted patients is largely attributable to the emergence of leukemic clones with mutations in the tyrosine kinase domain of BCR-ABL. Ongoing studies with newer TKIs will determine whether these more potent agents are able to sustain remissions without SCT. Assessment of minimal residual disease has become an integral part of the management of Ph+ALL, as it has prognostic importance and is used to guide therapeutic intervention. Novel immunotherapeutic interventions and combinations of TKIs are currently being investigated in clinical trials and may further improve the prognosis of patients with Ph+ALL.
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Affiliation(s)
- O G Ottmann
- Department of Medicine, Hematology and Oncology, Johann-Wolfgang Goethe University, Frankfurt, Germany
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28
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Chemotherapy-induced peripheral neurotoxicity (CIPN): An update. Crit Rev Oncol Hematol 2012; 82:51-77. [DOI: 10.1016/j.critrevonc.2011.04.012] [Citation(s) in RCA: 369] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 04/21/2011] [Accepted: 04/28/2011] [Indexed: 11/21/2022] Open
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29
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Milojkovic D, Ibrahim A, Reid A, Foroni L, Apperley J, Marin D. Efficacy of combining dasatinib and FLAG-IDA for patients with chronic myeloid leukemia in blastic transformation. Haematologica 2011; 97:473-4. [PMID: 22133777 DOI: 10.3324/haematol.2011.057513] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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30
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Rousselot P, Delannoy A. Optimal Pharmacotherapeutic Management of Acute Lymphoblastic Leukaemia in the Elderly. Drugs Aging 2011; 28:749-64. [DOI: 10.2165/11592850-000000000-00000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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31
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Schultz KR, Prestidge T, Camitta B. Philadelphia chromosome-positive acute lymphoblastic leukemia in children: new and emerging treatment options. Expert Rev Hematol 2011; 3:731-42. [PMID: 21091149 DOI: 10.1586/ehm.10.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Philadelphia chromosome-positive (Ph(+)) acute lymphoblastic leukemia (ALL) in children and adolescents has, until recently, been considered one of the poorest-risk subgroups of ALL. With chemotherapy alone, only 20-30% of children with Ph(+) ALL are cured. Allogeneic hematopoietic cell transplantation in first complete remission cures 60% of patients with a closely matched donor. Although targeted tyrosine kinase inhibitors (TKIs) have limited activity against Ph(+) ALL as a single agent, they have been evaluated in combination with chemotherapy with promising results. The early results of Children's Oncology Group trial AALL0031 have shown 88% 3-year event-free survival for Ph(+) patients treated with intensive chemotherapy plus continuous-dosing imatinib. This suggests that chemotherapy plus TKIs may be the initial treatment of choice for Ph(+) ALL in children. However, the numbers are small in this trial and confirmatory results are not yet available from the European Intergroup Study on Post Induction Treatment of Philadelphia Positive Acute Lymphoblastic Leukaemia with Imatinib trial. Additional issues include determining the most effective TKI (imatinib, dasatinib or nilotinib) and the most effective, least toxic chemotherapy backbone. The experience of adding a targeted agent such as a TKI to the standard chemotherapy regimen suggests that this strategy might be applied to other ALL subtypes to achieve both increased efficacy and decreased toxicity.
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Affiliation(s)
- Kirk R Schultz
- Division of Pedatric Hematology, Oncology, Blood and Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
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32
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Chabrol A, Cuzin L, Huguet F, Alvarez M, Verdeil X, Linas MD, Cassaing S, Giron J, Tetu L, Attal M, Récher C. Prophylaxis of invasive aspergillosis with voriconazole or caspofungin during building work in patients with acute leukemia. Haematologica 2010; 95:996-1003. [PMID: 20007135 PMCID: PMC2878800 DOI: 10.3324/haematol.2009.012633] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 11/03/2009] [Accepted: 11/19/2009] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Invasive aspergillosis is a common life-threatening infection in patients with acute leukemia. The presence of building work near to hospital wards in which these patients are cared for is an important risk factor for the development of invasive aspergillosis. This study assessed the impact of voriconazole or caspofungin prophylaxis in patients undergoing induction chemotherapy for acute leukemia in a hematology unit exposed to building work. DESIGN AND METHODS This retrospective cohort study was carried out between June 2003 and January 2006 during which building work exposed patients to a persistently increased risk of invasive aspergillosis. This study compared the cumulative incidence of invasive aspergillosis in patients who did or did not receive primary antifungal prophylaxis. The diagnosis of invasive aspergillosis was based on the European Organization for Research and Treatment of Cancer/Mycosis Study Group criteria. RESULTS Two-hundred and fifty-seven patients (213 with acute myeloid leukemia, 44 with acute lymphocytic leukemia) were included. The mean age of the patients was 54 years and the mean duration of their neutropenia was 21 days. Eighty-eight received antifungal prophylaxis, most with voriconazole (n=74). The characteristics of the patients who did or did not receive prophylaxis were similar except that pulmonary antecedents (chronic bronchopulmonary disorders or active tobacco use) were more frequent in the prophylaxis group. Invasive aspergillosis was diagnosed in 21 patients (12%) in the non-prophylaxis group and four (4.5%) in the prophylaxis group (P=0.04). Pulmonary antecedents, neutropenia at diagnosis and acute myeloid leukemia with high-risk cytogenetics were positively correlated with invasive aspergillosis, whereas primary prophylaxis was negatively correlated. Survival was similar in both groups. No case of zygomycosis was observed. The 3-month mortality rate was 28% in patients with invasive aspergillosis. CONCLUSIONS This study suggests that antifungal prophylaxis with voriconazole could be useful in acute leukemia patients undergoing first remission-induction chemotherapy in settings in which there is a high-risk of invasive aspergillosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Laurent Tetu
- Department of Pulmonary Diseases, Toulouse University Hospital, Toulouse, France
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Klyuchnikov E, Kröger N, Brummendorf TH, Wiedemann B, Zander AR, Bacher U. Current Status and Perspectives of Tyrosine Kinase Inhibitor Treatment in the Posttransplant Period in Patients with Chronic Myelogenous Leukemia (CML). Biol Blood Marrow Transplant 2010; 16:301-10. [DOI: 10.1016/j.bbmt.2009.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Accepted: 08/31/2009] [Indexed: 01/08/2023]
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A pilot study of carboplatin and mitoxantrone in blast crisis of chronic myeloid leukemia. Med Oncol 2009; 27:728-35. [DOI: 10.1007/s12032-009-9276-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
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Iyoda M, Shibata T, Kawaguchi M, Yamaoka T, Akizawa T. Preventive and therapeutic effects of imatinib in Wistar-Kyoto rats with anti-glomerular basement membrane glomerulonephritis. Kidney Int 2009; 75:1060-70. [PMID: 19242505 DOI: 10.1038/ki.2009.43] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Imatinib is a selective tyrosine kinase inhibitor that can block activity of the platelet-derived growth factor receptor (PDGFR) and that has immunomodulatory effects on various cell types. Here we measured the protective effects of imatinib in Wistar-Kyoto rats with nephrotoxic serum nephritis, a kidney disease model where CD8+ T cells and macrophages play pathogenetic roles. Groups of animals were given imatinib from one day before up to 13 days following induction of nephritis and from day 7 to 20 following disease induction. Compared to control rats, at each time point imatinib treatment caused significantly less proteinuria, lowered serum blood urea nitrogen and creatinine, and decreased the number of glomeruli with necrosis, crescents, and fibrin deposits. Imatinib-treated rats had a significant reduction in glomerular macrophage accumulation and reduced renal cortical PDGFR-beta and M-CSF receptor mRNA expression. Using colocalization we found that glomerular macrophages had reduced IL-1beta and MCP-1 protein expression. Late imatinib treatment significantly reduced proteinuria, serum blood urea nitrogen, and creatinine, and reversed renal histopathological changes. We show that imatinib has renoprotective and therapeutic properties and provide pre-clinical work that will need to be confirmed in patients with crescentic glomerulonephritis.
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Affiliation(s)
- Masayuki Iyoda
- Division of Nephrology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan.
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Abstract
While cure rates of over 80% are achieved in contemporary pediatric acute lymphoblastic leukemia (ALL) protocols, most adults with ALL succumb to their disease, and little progress has been made in the treatment of refractory and relapsed ALL. Moreover, the burden of therapy is high in a significant number of newly diagnosed patients, and in all those with relapse. Early response to therapy measured by minimal residual disease evaluation has proven the single most important prognostic factor and is increasingly used in risk stratification. However, as the benefit from intensification of frontline therapy becomes limiting, it becomes increasingly challenging to rescue patients who fail on contemporary risk-adapted protocols. New therapeutic strategies are needed, not only in salvage regimens but also in frontline protocols for patients who are at high risk of relapse. Current novel approaches include new formulations of existing chemotherapeutic agents, new antimetabolites and nucleoside analogs, monoclonal antibodies against leukemic-associated antigens, cellular immunotherapy, and molecular therapeutics. Some have already been adopted into standard regimens, while others remain in early stages of development. This review summarizes the current status of these novel therapies as they get integrated into ALL regimens.
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Affiliation(s)
- Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Merante S, Colombo AA, Calatroni S, Rocca B, Boni M, Bernasconi P, Bonvini L, Soverini S, Alessandrino EP. Nilotinib restores long-term full-donor chimerism in Ph-positive acute lymphoblastic leukemia relapsed after allogeneic transplantation. Bone Marrow Transplant 2009; 44:263-4. [PMID: 19204710 DOI: 10.1038/bmt.2009.6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Yanada M, Sugiura I, Takeuchi J, Akiyama H, Maruta A, Ueda Y, Usui N, Yagasaki F, Yujiri T, Takeuchi M, Nishii K, Kimura Y, Miyawaki S, Narimatsu H, Miyazaki Y, Ohtake S, Jinnai I, Matsuo K, Naoe T, Ohno R. Prospective monitoring of BCR-ABL1 transcript levels in patients with Philadelphia chromosome-positive acute lymphoblastic leukaemia undergoing imatinib-combined chemotherapy. Br J Haematol 2009; 143:503-10. [PMID: 18986386 DOI: 10.1111/j.1365-2141.2008.07377.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The clinical significance of minimal residual disease (MRD) is uncertain in patients with Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL) treated with imatinib-combined chemotherapy. Here we report the results of prospective MRD monitoring in 100 adult patients. Three hundred and sixty-seven follow-up bone marrow samples, collected at predefined time points during a uniform treatment protocol, were analysed for BCR-ABL1 transcripts by quantitative reverse transcription polymerase chain reaction. Ninety-seven patients (97%) achieved complete remission (CR), and the relapse-free survival (RFS) rate was 46% at 3 years. Negative MRD at the end of induction therapy was not associated with longer RFS or a lower relapse rate (P = 0.800 and P = 0.964 respectively). Twenty-nine patients showed MRD elevation during haematological CR. Of these, 10 of the 16 who had undergone allogeneic haematopoietic stem cell transplantation (HSCT) in first CR were alive without relapse at a median of 2.9 years after transplantation, whereas 12 of the 13 who had not undergone allogeneic HSCT experienced a relapse. These results demonstrate that, in Ph+ ALL patients treated with imatinib-combined chemotherapy, rapid molecular response is not associated with a favourable prognosis, and that a single observation of elevated MRD is predictive of subsequent relapse, but allogeneic HSCT can override its adverse effect.
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Affiliation(s)
- Masamitsu Yanada
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Abstract
AbstractThe tyrosine kinase inhibitor (TKI) imatinib has become an integral part of front-line therapy for Ph+ ALL, with remission rates exceeding 90% irrespective of whether imatinib is given alone or combined with chemotherapy. Treatment outcome with imatinib-based regimens has improved compared with historic controls, but most patients who do not undergo allogeneic stem cell transplantation (SCT) eventually relapse. Acquired resistance on TKI treatment is associated with mutations in the bcr-abl tyrosine kinase domain in the majority of patients, and may be detected at low frequency prior to TKI treatment in a subset of patients. Second generation TKIs, eg, dasatinib and nilotinib, show activity against most of the bcr-abl tyrosine kinase domain (TKD) mutations involved in acquired imatinib resistance, but clinical benefit is generally short-lived. Accordingly, SCT in first complete remission (CR) is considered to be the best curative option. Molecular monitoring of minimal residual disease levels appears to have prognostic relevance and should be used to guide treatment. International standardization and quality control efforts are ongoing to ensure comparability of results. Mutation analysis during treatment relies increasingly on highly sensitive PCR techniques or denaturing HPLC and may assist in treatment decisions, eg, in case of molecular relapse. Results from current studies of second-generation TKI as front-line treatment for Ph+ ALL are promising and show high molecular response rates, but follow-up is still too short to determine their impact on remission duration and long-term survival. Strategies to improve outcome after SCT include the pre-emptive use of imatinib, which appears to reduce the relapse rate. In patients ineligible for transplantation, novel concepts for maintenance therapy are needed. These could involve novel immunotherapeutic interventions and combinations of TKI.
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Liapis K, Apostolidis J, Charitaki E, Panitsas F, Harhalakis N, Nikiforakis E. Syndrome of inappropriate secretion of antidiuretic hormone associated with imatinib. Ann Pharmacother 2008; 42:1882-6. [PMID: 19017824 DOI: 10.1345/aph.1l410] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe a patient with Bcr-abl(+) acute lymphoblastic leukemia who developed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) while being treated with high-dose imatinib. CASE SUMMARY A 29-year-old woman was diagnosed with Bcr-abl(+) acute lymphoblastic leukemia, and treatment was initiated with chemotherapy and imatinib 800 mg daily. Following imatinib initiation, a gradual decrease in serum sodium level was noticed. Prolonged aplasia and neutropenic fever prompted discontinuation of therapy for 4 weeks. Following the patient's recovery, complete remission was achieved and monotherapy with imatinib 800 mg daily was restarted; however, hyponatremia recurred a few days later. The clinical findings and laboratory workup were compatible with the diagnosis of SIADH, which was attributed to high-dose imatinib. Fluid restriction and imatinib dosage reduction (to 600 mg/day) restored sodium levels. According to the Naranjo probability scale, this adverse reaction was probably associated with imatinib. DISCUSSION Imatinib emerged as the first tyrosine kinase inhibitor to enter everyday clinical practice for the treatment of Ph(+) leukemias. Due to its molecular specificity, imatinib lacks the broad cytotoxicity of conventional chemotherapy. Inhibition of kinases in normal tissues accounts for many of imatinib's adverse reactions. To our knowledge, this is the first reported case of imatinib-induced SIADH. CONCLUSIONS We recommend monitoring for SIADH if a patient receiving high-dose imatinib develops hyponatremia.
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Affiliation(s)
- Konstantinos Liapis
- Department of Hematology and Lymphoma, Evangelismos Hospital, Athens, Greece.
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Jones D, Thomas D, Yin CC, O'Brien S, Cortes JE, Jabbour E, Breeden M, Giles FJ, Zhao W, Kantarjian HM. Kinase domain point mutations in Philadelphia chromosome-positive acute lymphoblastic leukemia emerge after therapy with BCR-ABL kinase inhibitors. Cancer 2008; 113:985-94. [PMID: 18615627 DOI: 10.1002/cncr.23666] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND BCR-ABL kinase domain (KD) mutations are detected in approximately 45% of patients with imatinib-resistant chronic myeloid leukemia. Patterns of KD mutations in Philadelphia chromosome (Ph)-positive acute lympho- blastic leukemia (ALL) are less well studied. METHODS The authors assessed KD mutations in patients with recurrent Ph-positive ALL after treatments that included 1 or more kinase inhibitors (n = 24 patients) or no prior kinase inhibitor (KI) therapy (n = 12 patients). RESULTS ABL KD mutations were detected by direct sequencing in 15 of 17 patients (88%) who had recurrent Ph-positive ALL and received prior imatinib (n = 16) or dasatinib (n = 1) treatment and in 6 of 7 patients (86%) who had resistant/recurrent tumors treated with >or=2 KIs compared with 0 of 12 patients with recurrent Ph-positive ALL who never received KIs. A restricted set of mutations was observed, mostly Y253H and T315I, and were detected on average 10 months after KI initiation, and mutations were not detected in the initial tumor samples before KI therapy in 12 patients who were assessed. Using a more sensitive pyrosequencing method, mutations were not detected at codons 315 and 253 in the diagnostic samples from those 12 patients or in 30 patients with Ph-positive ALL who never developed recurrent disease. CONCLUSIONS ABL KD mutations, especially at codons 315 and 253, emerged at the time of disease recurrence in the vast majority of patients who had Ph-positive ALL and received maintenance KI therapy. Thus, the authors concluded that ongoing KI exposure may alter the patterns of recurrence and favor the outgrowth of clones with KI-resistant mutations.
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Affiliation(s)
- Dan Jones
- Department of Hematopathology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Targeting survival cascades induced by activation of Ras/Raf/MEK/ERK, PI3K/PTEN/Akt/mTOR and Jak/STAT pathways for effective leukemia therapy. Leukemia 2008; 22:708-22. [PMID: 18337766 DOI: 10.1038/leu.2008.27] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Raf/MEK/ERK, PI3K/PTEN/Akt/mTOR and Jak/STAT pathways are frequently activated in leukemia and other hematopoietic disorders by upstream mutations in cytokine receptors, aberrant chromosomal translocations as well as other genetic mechanisms. The Jak2 kinase is frequently mutated in many myeloproliferative disorders. Effective targeting of these pathways may result in suppression of cell growth and death of leukemic cells. Furthermore it may be possible to combine various chemotherapeutic and antibody-based therapies with low molecular weight, cell membrane-permeable inhibitors which target the Raf/MEK/ERK, PI3K/PTEN/Akt/mTOR and Jak/STAT pathways to ultimately suppress the survival pathways, induce apoptosis and inhibit leukemic growth. In this review, we summarize how suppression of these pathways may inhibit key survival networks important in leukemogenesis and leukemia therapy as well as the treatment of other hematopoietic disorders. Targeting of these and additional cascades may also improve the therapy of chronic myelogenous leukemia, which are resistant to BCR-ABL inhibitors. Furthermore, we discuss how targeting of the leukemia microenvironment and the leukemia stem cell are emerging fields and challenges in targeted therapies.
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Rezaï K, Lokiec F, Grandjean I, Weill S, de Cremoux P, Bordier V, Ekue R, Garcia M, Poupon MF, Decaudin D. Impact of imatinib on the pharmacokinetics and in vivo efficacy of etoposide and/or ifosfamide. BMC Pharmacol 2007; 7:13. [PMID: 17963518 PMCID: PMC2180168 DOI: 10.1186/1471-2210-7-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 10/27/2007] [Indexed: 12/28/2022] Open
Abstract
Background Using a human small cell lung cancer (SCLC) xenografted in nude mice, we have previously reported enhanced tumor growth inhibition following chemotherapy in combination with imatinib (STI571). We therefore investigated the in vivo impact of imatinib on the pharmacokinetics and efficacy of chemotherapy. Methods Two different human tumors were used: SCLC6 small cell lung cancer xenografted in nude mice, and LY-3 EBV-associated human B-cell lymphoma xenografted in SCID mice. Plasma, urine, and fecal concentrations of etoposide (VP16) were determined by a validated high performance liquid chromatography method. Plasma concentrations of ifosfamidewere determined by a validated gas chromatography assay with nitrogen-phosphorus detection. Results Slight tumor growth inhibition was induced by imatinib administered alone in one in vivo EBV-associated B-cell lymphomatous xenograft. In contrast, an increase of the chemotherapy-induced antitumor effect was observed in the lymphoma model but not in a small cell lung cancer model when mice bearing human xenografted tumors were treated concomitantly by imatinib and chemotherapy. This antitumor effect was not influenced by concomitant administration of fluconazole. The AUC0-3 h (Area Under the concentration-time Curve) of etoposide was increased when mice were treated with etoposide + imatinib due to decreased fecal excretion. In contrast, imatinib did not appear to influence the urinary excretion of etoposide, and concomitant administration of the CYP3A4 inhibitor, fluconazole, with imatinib did not modify the pharmacokinetics of etoposide plus imatinib alone. Conclusion Altogether, these results therefore justify further prospective phase I and II clinical trials with combinations of etoposide-based chemotherapy and imatinib in patients with certain cancers, such as malignant lymphoma, with careful toxicologic monitoring.
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Affiliation(s)
- Keyvan Rezaï
- Department of Clinical Hematology, Institut Curie, Paris, France.
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Coşkun HS, Göksu SS, Sahin M, Alanoğlu G. Bleomycin, etoposide and cisplatin (BEP) combination with concurrent imatinib mesylate (GLEEVEC) in chronic myeloid leukemia (CML) patient with mesenchymal tumor. Med Oncol 2007; 25:110-2. [PMID: 18188725 DOI: 10.1007/s12032-007-0053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 07/27/2007] [Indexed: 10/22/2022]
Abstract
Imatinib is now indicated as the first line therapy for chronic myeloid leukemia (CML). Treatment of CML with imatinib is generally well tolerated and the risk of severe adverse affects is low. Many new drugs including targeted therapy are combined with antineoplastic agents safely. We here report a patient with CML who developed concurrent mesenchymal tumor while undergoing therapy with imatinib and treated with combination chemotherapy including bleomycin, etoposide, and cisplatin, as well as imatinib without severe toxicity.
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Affiliation(s)
- Hasan Senol Coşkun
- Medical Faculty, Department of Medical Oncology, Süleyman Demirel University, Isparta, 32040, Turkey.
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Nishii K, Sakakura M, Tsukada T, Ryuu H, Katayama N. Successful treatment with imatinib combined with less intensive chemotherapy (vincristine and dexamethasone) as induction therapy in a very elderly patient with Philadelphia chromosome-positive acute lymphoblastic leukemia. Int J Hematol 2007; 85:273-4. [PMID: 17483068 DOI: 10.1532/ijh97.06216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ottmann O, Dombret H, Martinelli G, Simonsson B, Guilhot F, Larson RA, Rege-Cambrin G, Radich J, Hochhaus A, Apanovitch AM, Gollerkeri A, Coutre S. Dasatinib induces rapid hematologic and cytogenetic responses in adult patients with Philadelphia chromosome positive acute lymphoblastic leukemia with resistance or intolerance to imatinib: interim results of a phase 2 study. Blood 2007; 110:2309-15. [PMID: 17496201 DOI: 10.1182/blood-2007-02-073528] [Citation(s) in RCA: 266] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients with Philadelphia (Ph) chromosome-positive acute lymphoblastic leukemia (ALL) have a rapid disease course and a poor prognosis. Dasatinib, a novel, oral, multitargeted kinase inhibitor of BCR-ABL and SRC family kinases, has previously induced responses in patients with imatinib-resistant or -intolerant Ph-positive ALL. We present the interim results of a phase 2 study designed to further assess the efficacy, safety, and tolerability of dasatinib 140 mg in this patient population (n = 36). With a minimum follow-up of 8 months, treatment with dasatinib resulted in substantial hematologic and cytogenetic response rates. Major hematologic responses were achieved in 42% (15/36) of patients, 67% of whom remained progression-free. Complete cytogenetic responses were attained by 58% (21/36) of patients. The presence of BCR-ABL mutations conferring imatinib resistance did not preclude a response to dasatinib. Dasatinib was also tolerable, with 6% (2/36) of patients discontinuing therapy as a result of study-drug toxicity. Most adverse events (AEs) were grade 1 or 2; febrile neutropenia was the most frequent severe AE, but this and other cytopenias were manageable with dose reduction. Dasatinib represents a safe and effective treatment option and an important therapeutic advance for patients with Ph-positive ALL. This trial was registered at www.clinicaltrials.gov as #CA180015.
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Affiliation(s)
- Oliver Ottmann
- Medizinische Klinik II, Johann Wolfgang Goethe Universität, Frankfurt, Germany.
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Pui CH, Jeha S. New therapeutic strategies for the treatment of acute lymphoblastic leukaemia. Nat Rev Drug Discov 2007; 6:149-65. [PMID: 17268486 DOI: 10.1038/nrd2240] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although contemporary treatments cure more than 80% of children with acute lymphoblastic leukaemia (ALL), some patients require intensive treatment and many patients still develop serious acute and late complications owing to the side effects of the treatments. Furthermore, the survival rate for adults with ALL remains below 40%. Therefore, new treatment strategies are needed to improve not only the cure rate but also the quality of life of these patients. Here, we discuss emerging new treatments that might improve the clinical outcome of patients with ALL. These include new formulations of existing chemotherapeutic agents, new antimetabolites and nucleoside analogues, monoclonal antibodies against leukaemia-associated antigens, and molecular therapies that target genetic abnormalities of the leukaemic cells and their affected signalling pathways.
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Affiliation(s)
- Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, 332 North Lauderdale Street, Memphis, Tennessee 38105, USA.
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Orciuolo E, Buda G, Galimberti S, Cecconi N, Cervetti G, Petrini M. Concomitant translocation t(14;22)(q32;q11) in a case of chronic myeloid leukemia. Leuk Res 2007; 32:188-90. [PMID: 17346791 DOI: 10.1016/j.leukres.2007.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 01/26/2007] [Accepted: 01/29/2007] [Indexed: 10/23/2022]
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Sinai P, Berg RE, Haynie JM, Egorin MJ, Ilaria RL, Forman J. Imatinib Mesylate Inhibits Antigen-Specific Memory CD8 T Cell Responses In Vivo. THE JOURNAL OF IMMUNOLOGY 2007; 178:2028-37. [PMID: 17277106 DOI: 10.4049/jimmunol.178.4.2028] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Imatinib mesylate (IM) is effective at inducing complete cytogenetic remission in patients with chronic myelogenous leukemia. Because its influence on CD8 T cell responsiveness in vivo is unknown, we investigated the effects of IM by analyzing the response of OT-1 CD8 T cells to Listeria monocytogenes (LM) that express the cognate epitope OVA(257-264) (LM-OVA). In vitro, IM had no effect on Ag-specific expansion, cell division, cell cycle progression, or IFN-gamma expression in naive or memory OT-1 T cells. However, IM induced apoptosis of naive and memory OT-1 T cells at doses of >5 microM. At 15 microM IM, OT-1 T cells did not survive in in vitro cultures. The primary response of OT-1 T cells in vivo to LM-OVA infection was unaltered. In contrast, continuous IM treatment resulted in a diminished memory OT-1 response. The expression of IL-7Ralpha, a receptor required for memory cell survival, was lower (on OT-1 cells) in animals receiving IM. These results indicate that IM treatment affects the ability of the CD8 memory pool to respond to Ag and has the potential to increase susceptibility to infection.
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Affiliation(s)
- Parisa Sinai
- Center for Immunology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Kovacsovics T, Maziarz RT. Philadelphia chromosome-positive acute lymphoblastic leukemia: impact of imatinib treatment on remission induction and allogeneic stem cell transplantation. Curr Oncol Rep 2007; 8:343-51. [PMID: 16901395 DOI: 10.1007/s11912-006-0056-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) has been associated with the worst patient survival rates of the various acute leukemias. Imatinib mesylate is a novel therapeutic agent that targets the BCR-ABL tyrosine kinase, the molecular abnormality associated with Ph+ ALL. The combination of imatinib with chemotherapy has led to improved and durable treatment responses in adult patients with Ph+ ALL, including the elderly population. Hematopoietic stem cell transplantation has also integrated imatinib into its transplant strategies, with early data suggesting improved progression-free survival without clearly identifiable augmented toxicity. Second-generation tyrosine kinase inhibitors offer potentially even greater improvements on these excellent imatinib-associated outcomes. This review addresses the evolution of the management of Ph+ ALL and is intended to assist in the description of its new natural history.
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