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Bidikian A, Jabbour E, Issa GC, Short NJ, Sasaki K, Kantarjian H. Chronic myeloid leukemia without major molecular response after 2 years of treatment with tyrosine kinase inhibitor. Am J Hematol 2023; 98:639-644. [PMID: 36606715 DOI: 10.1002/ajh.26836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/28/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
Achieving major molecular response (MMR) with BCR::ABL1 tyrosine kinase inhibitors (TKIs) is associated with lower chances of progression to advanced phase disease and higher chances of treatment-free remission (TFR) in patients with chronic myeloid leukemia (CML). Failure to achieve this molecular milestone after 1 year has been highlighted as "suboptimal" or "warning" sign of treatment failure in CML guidelines and recommendations and implied to predict a poor long-term outcome. In this analysis, we report the long-term outcome of 131 patients who did not achieve MMR within the first 2 years of TKI therapy. Patients who achieved a major cytogenetic response (MCyR; roughly equivalent to BCR::ABL1 transcript levels on the International Scale [IS] <10%) had good long-term overall survival (OS) (10-year OS of 88%) and CML-related overall survival (CML-OS) (10-year CML-OS of 95%). The achievement of MCyR within the first 2 years of treatment predicted a better OS (HR = 0.43, p = .03). The value of MMR was even less pronounced among patients aged 60 years or older at diagnosis, in whom mortality was primarily due to comorbidities unrelated to CML (10-year OS of 55% vs. 10-year CML-OS of 100%). In conclusion, achievement of MCyR within 2 years is a reasonable milestone in CML, and these patients can still have good outcomes even when MMR is not achieved.
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Affiliation(s)
- Aram Bidikian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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2
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Shelton DN, Bhagavatula P, Sepulveda N, Beppu L, Gandhi S, Qin D, Hauenstein S, Radich J. Performance characteristics of the first Food and Drug Administration (FDA)-cleared digital droplet PCR (ddPCR) assay for BCR::ABL1 monitoring in chronic myelogenous leukemia. PLoS One 2022; 17:e0265278. [PMID: 35298544 PMCID: PMC8929598 DOI: 10.1371/journal.pone.0265278] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/27/2022] [Indexed: 11/19/2022] Open
Abstract
Chronic myelogenous leukemia (CML) is a hematopoietic stem cell malignancy that accounts for 15-20% of all cases of leukemia. CML is caused by a translocation between chromosomes 9 and 22 which creates an abnormal fusion gene, BCR::ABL1. The amount of BCR::ABL1 transcript RNA is a marker of disease progression and the effectiveness of tyrosine kinase inhibitor (TKI) treatment. This study determined the analytical and clinical performance of a droplet digital PCR based assay (QXDx BCR-ABL %IS Kit; Bio-Rad) for BCR::ABL1 quantification. The test has a limit of detection of MR4.7 (0.002%) and a linear range of MR0.3-4.7 (50-0.002%IS). Reproducibility of results across multiple sites, days, instruments, and users was evaluated using panels made from BCR::ABL1 positive patient samples. Clinical performance of the assay was evaluated on patient samples and compared to an existing FDA-cleared test. The reproducibility study noted negligible contributions to variance from site, instrument, day, and user for samples spanning from MR 0.7-4.2. The assay demonstrated excellent clinical correlation with the comparator test using a Deming regression with a Pearson R of 0.99, slope of 1.037 and intercept of 0.1084. This data establishes that the QXDx™ BCR-ABL %IS Kit is an accurate, precise, and sensitive system for the diagnosis and monitoring of CML.
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MESH Headings
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Polymerase Chain Reaction/methods
- Protein Kinase Inhibitors/therapeutic use
- Reproducibility of Results
- United States
- United States Food and Drug Administration
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Affiliation(s)
- Dawne N. Shelton
- Digital Biology Group, Bio-Rad Laboratories, Pleasanton, California, United States of America
| | - Prasanthi Bhagavatula
- Digital Biology Group, Bio-Rad Laboratories, Pleasanton, California, United States of America
| | - Nathan Sepulveda
- Digital Biology Group, Bio-Rad Laboratories, Pleasanton, California, United States of America
| | - Lan Beppu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Shital Gandhi
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Dahui Qin
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Scott Hauenstein
- Digital Biology Group, Bio-Rad Laboratories, Pleasanton, California, United States of America
| | - Jerald Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
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3
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Fenu E, O'Neill SS, Insuasti-Beltran G. BCR-ABL1 p210 screening for chronic myeloid leukemia in patients with peripheral blood cytoses. Int J Lab Hematol 2021; 43:1458-1464. [PMID: 34185393 DOI: 10.1111/ijlh.13635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Chronic myeloid leukemia (CML) usually presents with leukocytosis with neutrophilia, left shift, and basophilia. Documentation of the BCR-ABL1 fusion is required for diagnosis, and this is often achieved via p210 BCR-ABL1 real-time polymerase chain reaction (RT-PCR). METHODS Patients undergoing first-time testing for p210 BCR-ABL1 at our institution were retrospectively identified. The medical record was reviewed, and the patient age, sex, clinical indication for testing, and concurrent CBC with differential were identified for 518 patients. BCR-ABL1 p210 testing had been performed using a laboratory-developed quantitative RT-PCR assay. Statistical analysis of the results was performed using an unpaired t test, and P values of <.05 were considered statistically significant. RESULTS Twenty-four patients received a new diagnosis of CML (4.6%). As compared to patients with a negative PCR, these patients were more likely to have a markedly elevated white blood cell count (WBC), neutrophilia, and a mild anemia. Ninety-two percent (22/24) of new CML patients had a WBC ≥20 × 109 /L, and the two new CML patients with WBC <20 × 109 /L had basophilia in the peripheral blood. By contrast, 92% (449/490) of non-CML patients had a WBC <20 × 109 /L. CONCLUSION The peripheral blood parameters of total WBC ≥20 × 109 /L and absolute basophil count can help guide the need for BCR-ABL1 PCR testing, which can lead to more judicious test utilization, decreased healthcare costs, and decreased false positives, while keeping a high sensitivity for CML. This study also underscores the importance of obtaining a complete differential in patients for whom CML is suspected.
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Affiliation(s)
- Elena Fenu
- Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Stacey S O'Neill
- Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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4
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Deininger MW, Shah NP, Altman JK, Berman E, Bhatia R, Bhatnagar B, DeAngelo DJ, Gotlib J, Hobbs G, Maness L, Mead M, Metheny L, Mohan S, Moore JO, Naqvi K, Oehler V, Pallera AM, Patnaik M, Pratz K, Pusic I, Rose MG, Smith BD, Snyder DS, Sweet KL, Talpaz M, Thompson J, Yang DT, Gregory KM, Sundar H. Chronic Myeloid Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1385-1415. [PMID: 33022644 DOI: 10.6004/jnccn.2020.0047] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic myeloid leukemia (CML) is defined by the presence of Philadelphia chromosome (Ph) which results from a reciprocal translocation between chromosomes 9 and 22 [t(9;22] that gives rise to a BCR-ABL1 fusion gene. CML occurs in 3 different phases (chronic, accelerated, and blast phase) and is usually diagnosed in the chronic phase. Tyrosine kinase inhibitor therapy is a highly effective first-line treatment option for all patients with newly diagnosed chronic phase CML. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with chronic phase CML.
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Affiliation(s)
| | - Neil P Shah
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Jessica K Altman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Bhavana Bhatnagar
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | - Leland Metheny
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | - Kiran Naqvi
- The University of Texas MD Anderson Cancer Center
| | - Vivian Oehler
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Arnel M Pallera
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Keith Pratz
- Abramson Cancer Center at the University of Pennsylvania
| | - Iskra Pusic
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | - B Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - David T Yang
- University of Wisconsin Carbone Cancer Center; and
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Horne GA, Stobo J, Kelly C, Mukhopadhyay A, Latif AL, Dixon-Hughes J, McMahon L, Cony-Makhoul P, Byrne J, Smith G, Koschmieder S, BrÜmmendorf TH, Schafhausen P, Gallipoli P, Thomson F, Cong W, Clark RE, Milojkovic D, Helgason GV, Foroni L, Nicolini FE, Holyoake TL, Copland M. A randomised phase II trial of hydroxychloroquine and imatinib versus imatinib alone for patients with chronic myeloid leukaemia in major cytogenetic response with residual disease. Leukemia 2020; 34:1775-1786. [PMID: 31925317 PMCID: PMC7224085 DOI: 10.1038/s41375-019-0700-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/19/2022]
Abstract
In chronic-phase chronic myeloid leukaemia (CP-CML), residual BCR-ABL1+ leukaemia stem cells are responsible for disease persistence despite TKI. Based on in vitro data, CHOICES (CHlorOquine and Imatinib Combination to Eliminate Stem cells) was an international, randomised phase II trial designed to study the safety and efficacy of imatinib (IM) and hydroxychloroquine (HCQ) compared with IM alone in CP-CML patients in major cytogenetic remission with residual disease detectable by qPCR. Sixty-two patients were randomly assigned to either arm. Treatment 'successes' was the primary end point, defined as ≥0.5 log reduction in 12-month qPCR level from trial entry. Selected secondary study end points were 24-month treatment 'successes', molecular response and progression at 12 and 24 months, comparison of IM levels, and achievement of blood HCQ levels >2000 ng/ml. At 12 months, there was no difference in 'success' rate (p = 0.58); MMR was achieved in 80% (IM) vs 92% (IM/HCQ) (p = 0.21). At 24 months, the 'success' rate was 20.8% higher with IM/HCQ (p = 0.059). No patients progressed. Seventeen serious adverse events, including four serious adverse reactions, were reported; diarrhoea occurred more frequently with combination. IM/HCQ is tolerable in CP-CML, with modest improvement in qPCR levels at 12 and 24 months, suggesting autophagy inhibition maybe of clinical value in CP-CML.
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MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cytogenetic Analysis/methods
- Female
- Follow-Up Studies
- Fusion Proteins, bcr-abl/genetics
- Humans
- Hydroxychloroquine/administration & dosage
- Imatinib Mesylate/administration & dosage
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Male
- Middle Aged
- Prognosis
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- G A Horne
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - J Stobo
- Cancer Research UK Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - C Kelly
- Cancer Research UK Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - A Mukhopadhyay
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - A L Latif
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - J Dixon-Hughes
- Cancer Research UK Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - L McMahon
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - P Cony-Makhoul
- Haematology department, CH Annecy-Genevois, Pringy, France
| | - J Byrne
- Department of Haematology, Nottingham City Hospital, Nottingham, UK
| | - G Smith
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - S Koschmieder
- Department of Medicine (Hematology Oncology, Hemostaseology, and Stem Cell Transplantation), Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - T H BrÜmmendorf
- Department of Medicine (Hematology Oncology, Hemostaseology, and Stem Cell Transplantation), Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - P Schafhausen
- Department of Internal Medicine, University Medical Center Hamburg, Hamburg, Germany
| | - P Gallipoli
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - F Thomson
- Experimental therapeutics, Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - W Cong
- Experimental therapeutics, Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - R E Clark
- Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - D Milojkovic
- Department of Haematology, Hammersmith Hospital, London, UK
| | - G V Helgason
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - L Foroni
- Department of Haematology, Imperial College London, London, UK
| | - F E Nicolini
- Hématologie Clinique and INSERM U1052, CRCL, Centre Léon Bérard, Lyon, France
| | - T L Holyoake
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - M Copland
- Paul O'Gorman Leukaemia Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.
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6
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Moisoiu V, Teodorescu P, Parajdi L, Pasca S, Zdrenghea M, Dima D, Precup R, Tomuleasa C, Soverini S. Assessing Measurable Residual Disease in Chronic Myeloid Leukemia. BCR-ABL1 IS in the Avant-Garde of Molecular Hematology. Front Oncol 2019; 9:863. [PMID: 31608223 PMCID: PMC6768007 DOI: 10.3389/fonc.2019.00863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/20/2019] [Indexed: 11/17/2022] Open
Abstract
Chronic myelogenous leukemia (CML) is a malignancy of the myeloid cell lineage characterized by a recurrent chromosomal abnormality: the Philadelphia chromosome, which results from the reciprocal translocation of the chromosomes 9 and 22. The Philadelphia chromosome contains a fusion gene called BCR-ABL1. The BCR-ABL1 codes for an aberrantly functioning tyrosine kinase that drives the malignant proliferation of the founding clone. The advent of tyrosine kinase inhibitors (TKI) represents a landmark in the treatment of CML, that has led to tremendous improvement in the remission and survival rates. Since the introduction of imatinib, the first TKI, several other TKI have been approved that further broadened the arsenal against CML. Patients treated with TKIs require sensitive monitoring of BCR-ABL1 transcripts with quantitative real-time polymerase chain reaction (qRT-PCT), which has become an essential part of managing patients with CML. In this review, we discuss the importance of the BCR-ABL1 assay, and we highlight the growing importance of BCR-ABL1 dynamics. We also introduce a mathematical correction for the BCR-ABL1 assay that could help homogenizing the use of the ABL1 as a control gene. Finally, we discuss the growing body of evidence concerning treatment-free remission. Along with the continuous improvement in the therapeutic arsenal against CML, the molecular monitoring of CML represents the avant-garde in the struggle to make CML a curable disease.
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Affiliation(s)
- Vlad Moisoiu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
| | - Lorand Parajdi
- Department of Mathematics, Babes Bolyai University, Cluj Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
| | - Radu Precup
- Department of Mathematics, Babes Bolyai University, Cluj Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania
- Department of Hematology, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology L. and A. Seràgnoli, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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7
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Claudiani S, Gatenby A, Szydlo R, Nesr G, Abulafia AS, Palanicawandar R, Nteliopoulos G, Khorashad J, Foroni L, Apperley JF, Milojkovic D. MR4 sustained for 12 months is associated with stable deep molecular responses in chronic myeloid leukemia. Haematologica 2019; 104:2206-2214. [PMID: 30923102 PMCID: PMC6821602 DOI: 10.3324/haematol.2018.214809] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/21/2019] [Indexed: 12/25/2022] Open
Abstract
The majority of patients with newly diagnosed chronic myeloid leukemia (CML) will enjoy a life expectancy equivalent to that of unaffected individuals, but will remain on life-long treatment with a concomitant requirement for on-going hospital interactions for molecular monitoring and drug dispensing. In order to determine more accurately the frequency of monitoring required, we performed a 'real-life' retrospective single-center cohort study of 450 patients with CML in at least major molecular remission (MR3) to analyze the risk of loss of MR3 [defined as at least 2 consecutive real-time quantitative polymerase chain reaction (RT-qPCR) results >0.1% International Scale (IS)]. Patients who achieved sustained MR4 (sMR4, BCR-ABL1 RT-qPCR <0.01% IS for 12 months) had a probability of loss of MR3 at 1 and 5 years of 0 and 2.6% (95%CI: 1.2-5.4) respectively, compared to 4.4% (95%CI: 1.9-9.8) and 25.4% (95%CI: 16.7-36.7) respectively, in those who achieved sustained MR3 (sMR3) but not sMR4 (P<0.001). No patient who improved their response to a deep molecular level (at least MR4) lost MR3 if they were considered compliant, had no history of resistance and remained on standard dose tyrosine kinase inhibitor (TKI). MR4 maintained for at least one year represents a secure response threshold for patients with CML, after which no MR3 loss occurs if certain conditions are satisfied (standard TKI dose, full compliance, and lack of previous TKI resistance). This finding may justify reduction of the frequency of hospital interaction, with an associated positive impact on quality of life, survivorship, and economic burden to both patients and healthcare providers.
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Affiliation(s)
- Simone Claudiani
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK .,Centre for Haematology, Imperial College London, London, UK
| | - Aoife Gatenby
- Centre for Haematology, Imperial College London, London, UK
| | - Richard Szydlo
- Centre for Haematology, Imperial College London, London, UK
| | - George Nesr
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Imperial College London, London, UK
| | - Adi Shacham Abulafia
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Centre, Petah-Tiqva, Israel
| | - Renuka Palanicawandar
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Letizia Foroni
- Centre for Haematology, Imperial College London, London, UK
| | - Jane F Apperley
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Imperial College London, London, UK
| | - Dragana Milojkovic
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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8
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Patel AB, O'Hare T, Deininger MW. Mechanisms of Resistance to ABL Kinase Inhibition in Chronic Myeloid Leukemia and the Development of Next Generation ABL Kinase Inhibitors. Hematol Oncol Clin North Am 2017; 31:589-612. [PMID: 28673390 PMCID: PMC5505321 DOI: 10.1016/j.hoc.2017.04.007] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Chronic myeloid leukemia is increasingly viewed as a chronic illness; most patients have a life expectancy close to that of the general population. Despite progress made using BCR-ABL1 tyrosine kinase inhibitors (TKIs), drug resistance via BCR-ABL1-dependent and BCR-ABL1-independent mechanisms continues to be an issue. BCR-ABL1-dependent resistance is primarily mediated through oncoprotein kinase domain mutations and usually results in overt resistance to TKIs. However, BCR-ABL1-independent resistance in the setting of effective BCR-ABL1 inhibition is recognized as a major contributor to minimal residual disease. Efforts to eradicate persistent leukemic stem cells have focused on combination therapy.
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MESH Headings
- Antineoplastic Agents/chemistry
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biological Availability
- Biomarkers
- Cell Survival/drug effects
- Cell Survival/genetics
- Dose-Response Relationship, Drug
- Drug Discovery
- Drug Resistance, Neoplasm/genetics
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/chemistry
- Fusion Proteins, bcr-abl/genetics
- Gene Expression Regulation, Leukemic/drug effects
- Humans
- Immunotherapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Models, Molecular
- Molecular Targeted Therapy
- Mutation
- Protein Kinase Inhibitors/chemistry
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Signal Transduction/drug effects
- Structure-Activity Relationship
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Affiliation(s)
- Ami B Patel
- Department of Hematology and Oncology, Huntsman Cancer Institute, 2000 Circle of Hope Drive, The University of Utah, Salt Lake City, UT 84112, USA
| | - Thomas O'Hare
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, 2000 Circle of Hope Drive, Salt Lake City, UT 84112, USA
| | - Michael W Deininger
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, 2000 Circle of Hope Drive, Salt Lake City, UT 84112, USA.
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9
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High-throughput sequencing for noninvasive disease detection in hematologic malignancies. Blood 2017; 130:440-452. [PMID: 28600337 DOI: 10.1182/blood-2017-03-735639] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/25/2017] [Indexed: 12/20/2022] Open
Abstract
Noninvasive monitoring of minimal residual disease (MRD) has led to significant advances in personalized management of patients with hematologic malignancies. Improved therapeutic options and prolonged survival have further increased the need for sensitive tumor assessment that can inform treatment decisions and patient outcomes. At diagnosis or relapse of most hematologic neoplasms, malignant cells are often easily accessible in the blood as circulating tumor cells (CTCs), making them ideal targets to noninvasively profile the molecular features of each patient. In other cancer types, CTCs are generally rare and noninvasive molecular detection relies on circulating tumor DNA (ctDNA) shed from tumor deposits into circulation. The ability to precisely detect and quantify CTCs and ctDNA could minimize invasive procedures and improve prediction of clinical outcomes. Technical advances in MRD detection methods in recent years have led to reduced costs and increased sensitivity, specificity, and applicability. Among currently available tests, high-throughput sequencing (HTS)-based approaches are increasingly attractive for noninvasive molecular testing. HTS-based methods can simultaneously identify multiple genetic markers with high sensitivity and specificity without individual optimization. In this review, we present an overview of techniques used for noninvasive molecular disease detection in selected myeloid and lymphoid neoplasms, with a focus on the current and future role of HTS-based assays.
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10
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Kaygusuz Atagunduz I, Toptas T, Deniz R, Kara O, Eser A, Sezgin A, Ozgumus T, Gecgel F, Firatli Tuglular T. Effects of Deeper Molecular Responses on Outcomes in Chronic Myeloid Leukemia Patients in Chronic Phase Treated With Imatinib Mesylate. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:120-125. [DOI: 10.1016/j.clml.2016.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/03/2016] [Accepted: 09/08/2016] [Indexed: 11/30/2022]
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11
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Ailawadhi S, Akard LP, Miller CB, Jillella A, DeAngelo DJ, Ericson SG, Lin F, Warsi G, Radich J. Exploratory study on the impact of switching to nilotinib in 18 patients with chronic myeloid leukemia in chronic phase with suboptimal response to imatinib. Ther Adv Hematol 2016; 8:3-12. [PMID: 28042454 DOI: 10.1177/2040620716678118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The phase II, exploratory, open-label Exploring Nilotinib BCR-ABL Effects (ENABL) study [ClinicalTrials.gov identifier: NCT00644878] assessed the impact of switching to nilotinib therapy in patients with chronic myeloid leukemia in chronic phase (CML-CP) who had a suboptimal molecular response with imatinib. METHODS Patients with CML-CP who had previously achieved a complete cytogenetic response (CCyR), but had a suboptimal molecular response, with frontline imatinib therapy (N = 18) were assigned to receive nilotinib 300 mg twice daily. The primary endpoint was the change in BCR-ABL1 transcript levels from baseline after 12 months; rates of major molecular response (MMR) and safety were also assessed. RESULTS At 3 months after switching to nilotinib, 10 of 17 (59%) evaluable patients had achieved MMR. At 12 months, 9 of 12 (75%) evaluable patients had achieved MMR, and the median BCR-ABL1 level among all patients remaining in the study was 0.020% on the International Scale (IS), equivalent to a 3.7-log reduction from the standardized IS baseline (primary endpoint). Adverse events (AEs) were typically grade 1/2 and manageable with dose interruptions. A total of three patients experienced serious study drug-related AEs, including pancreatitis, bradycardia, and vertigo. No deaths were reported. CONCLUSIONS Overall, results from this exploratory study suggest that switching to nilotinib due to suboptimal molecular response with imatinib can result in improved molecular response for patients with CML-CP.
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Affiliation(s)
- Sikander Ailawadhi
- Division of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Luke P Akard
- Department of Hematology, Indiana Blood and Marrow Transplantation, Indianapolis, IN, USA
| | - Carole B Miller
- Departments of Internal Medicine and Medical Oncology, St. Agnes Hospital, Baltimore, MD, USA
| | - Anand Jillella
- Department of Medicine, Georgia Regents University, Augusta, GA, USA
| | | | | | - Felice Lin
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Ghulam Warsi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Jerald Radich
- Clinical Cancer Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Gillis NK, McLeod HL. The pharmacogenomics of drug resistance to protein kinase inhibitors. Drug Resist Updat 2016; 28:28-42. [PMID: 27620953 PMCID: PMC5022787 DOI: 10.1016/j.drup.2016.06.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/17/2016] [Accepted: 06/29/2016] [Indexed: 01/05/2023]
Abstract
Dysregulation of growth factor cell signaling is a major driver of most human cancers. This has led to development of numerous drugs targeting protein kinases, with demonstrated efficacy in the treatment of a wide spectrum of cancers. Despite their high initial response rates and survival benefits, the majority of patients eventually develop resistance to these targeted therapies. This review article discusses examples of established mechanisms of drug resistance to anticancer therapies, including drug target mutations or gene amplifications, emergence of alternate signaling pathways, and pharmacokinetic variation. This reveals a role for pharmacogenomic analysis to identify and monitor for resistance, with possible therapeutic strategies to combat chemoresistance.
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Affiliation(s)
- Nancy K Gillis
- Eshelman School of Pharmacy, Center for Pharmacogenomics and Individualized Therapy, University of North Carolina, Chapel Hill, NC, United States; H. Lee Moffitt Cancer Center and Research Institute, DeBartolo Family Personalized Medicine Institute, Tampa, FL, United States
| | - Howard L McLeod
- H. Lee Moffitt Cancer Center and Research Institute, DeBartolo Family Personalized Medicine Institute, Tampa, FL, United States; Xiangya Hospital, Central South University, Changsha, China.
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13
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Soverini S, De Benedittis C, Mancini M, Martinelli G. Present and future of molecular monitoring in chronic myeloid leukaemia. Br J Haematol 2016; 173:337-49. [PMID: 26947577 DOI: 10.1111/bjh.13966] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Currently, physicians treating chronic myeloid leukaemia (CML) patients can rely on a wide spectrum of therapeutic options: the best use of such options is essential to achieve excellent clinical outcomes and, possibly, treatment-free remission (TFR). To accomplish this, proper integration of expert clinical and laboratory monitoring of CML patients is fundamental. Molecular response (MR) monitoring of patients at defined time points has emerged as an important success factor for optimal disease management and BCR-ABL1 kinase domain mutation screening is useful to guide therapeutic reassessment in patients who do not achieve optimal responses to tyrosine kinase inhibitor therapy. Deeper MRs might be associated with improved long-term survival outcomes. More importantly, they are considered a gateway to TFR. In molecular biology, novel procedures and technologies are continually being developed. More sophisticated molecular tools and automated analytical solutions are emerging as CML treatment endpoints and expectations become more and more ambitious. Here we provide a critical overview of current and novel methodologies, present their strengths and pitfalls and discuss what their present and future role might be.
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Affiliation(s)
- Simona Soverini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Caterina De Benedittis
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Manuela Mancini
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Giovanni Martinelli
- Department of Experimental, Diagnostic and Specialty Medicine, Haematology/Oncology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
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14
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Is cure for chronic myeloid leukemia possible in the tyrosine kinase inhibitors era? Curr Opin Hematol 2016; 23:115-20. [DOI: 10.1097/moh.0000000000000224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Latham S, Bartley PA, Budgen B, Ross DM, Hughes E, Branford S, White D, Hughes TP, Morley AA. BCR-ABL1 expression, RT-qPCR and treatment decisions in chronic myeloid leukaemia. J Clin Pathol 2016; 69:817-21. [PMID: 26837312 DOI: 10.1136/jclinpath-2015-203538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/13/2016] [Indexed: 11/03/2022]
Abstract
AIMS RT-qPCR is used to quantify minimal residual disease (MRD) in chronic myeloid leukaemia (CML) in order to make decisions on treatment, but its results depend on the level of BCR-ABL1 expression as well as leukaemic cell number. The aims of the study were to quantify inter-individual differences in expression level, to determine the relationship between expression level and response to treatment, and to investigate the effect of expression level on interpretation of the RT-qPCR result. METHODS BCR-ABL1 expression was studied in 248 samples from 65 patients with CML by determining the difference between MRD quantified by RT-qPCR and DNA-qPCR. The results were analysed statistically and by simple indicative modelling. RESULTS Inter-individual levels of expression approximated a normal distribution with an SD of 0.36 log. Expression at diagnosis correlated with expression during treatment. Response to treatment, as measured by the number of leukaemic cells after 3, 6 or 12 months of treatment, was not related to the level of expression. Indicative modelling suggested that interpretation of RT-qPCR results in relation to treatment guidelines could be affected by variation in expression when MRD was around 10% at 3 months and by both expression variation and Poisson variation when MRD was around or below the limit of detection of RT-qPCR. CONCLUSIONS Variation between individuals in expression of BCR-ABL1 can materially affect interpretation of the RT-qPCR when this test is used to make decisions on treatment.
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Affiliation(s)
- Susan Latham
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Paul A Bartley
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Bradley Budgen
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - David M Ross
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia Haematology Division, SA Pathology, Adelaide, South Australia, Australia
| | - Elizabeth Hughes
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | - Susan Branford
- Centre for Cancer Biology, SA Pathology, Adelaide, South Australia, Australia
| | - Deborah White
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Timothy P Hughes
- Haematology Division, SA Pathology, Adelaide, South Australia, Australia
| | - Alexander A Morley
- Department of Haematology & Genetic Pathology, School of Medicine, Flinders University and Medical Centre, Bedford Park, South Australia, Australia Monoquant Pty Ltd, Adelaide, South Australia, Australia
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16
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Brümmendorf TH, Cortes JE, Khoury HJ, Kantarjian HM, Kim DW, Schafhausen P, Conlan MG, Shapiro M, Turnbull K, Leip E, Gambacorti-Passerini C, Lipton JH. Factors influencing long-term efficacy and tolerability of bosutinib in chronic phase chronic myeloid leukaemia resistant or intolerant to imatinib. Br J Haematol 2015; 172:97-110. [PMID: 26537529 PMCID: PMC4737299 DOI: 10.1111/bjh.13801] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 11/28/2022]
Abstract
The dual SRC/ABL1 tyrosine kinase inhibitor bosutinib is indicated for adults with Ph+ chronic myeloid leukaemia (CML) resistant/intolerant to prior therapy. This analysis of an ongoing phase 1/2 study (NCT00261846) assessed effects of baseline patient characteristics on long‐term efficacy and safety of bosutinib 500 mg/day in adults with imatinib (IM)‐resistant (IM‐R; n = 196)/IM‐intolerant (IM‐I; n = 90) chronic phase (CP) CML. Median treatment duration was 24·8 months (median follow‐up, 43·6 months). Cumulative major cytogenetic response (MCyR) rate [95% confidence interval (CI)], was 59% (53–65%); Kaplan‐Meier (KM) probability of maintaining MCyR at 4 years was 75% (66–81%). Cumulative incidence of on‐treatment progression/death at 4 years was 19% (95% CI, 15–24%); KM 2‐year overall survival was 91% (87–94%). Significant baseline predictors of both MCyR and complete cytogenetic response (newly attained/maintained from baseline) at 3 and 6 months included prior IM cytogenetic response, baseline MCyR, prior interferon therapy and <6 months duration from diagnosis to IM treatment initiation and no interferon treatment before IM. The most common adverse event (AE) was diarrhoea (86%). Baseline bosutinib‐sensitive BCR‐ABL1 mutation was the only significant predictor of grade 3/4 diarrhoea; no significant predictors were identified for liver‐related AEs. Bosutinib demonstrates durable efficacy and manageable toxicity in IM‐R/IM‐I CP‐CML patients.
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Affiliation(s)
- Tim H Brümmendorf
- Universitätsklinikum RWTH Aachen, Aachen, Germany.,Department of Internal Medicine II, Hubertus Wald Tumorzentrum University Cancer Centre Hamburg, Hamburg, Germany
| | - Jorge E Cortes
- University of Texas MD, Anderson Cancer Center, Houston, TX, USA
| | - Hanna J Khoury
- Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | | | | | - Philippe Schafhausen
- Department of Internal Medicine II, Hubertus Wald Tumorzentrum University Cancer Centre Hamburg, Hamburg, Germany
| | | | | | | | | | | | - Jeff H Lipton
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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17
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Recchia AG, Caruso N, Bossio S, Pellicanò M, De Stefano L, Franzese S, Palummo A, Abbadessa V, Lucia E, Gentile M, Vigna E, Caracciolo C, Agostino A, Galimberti S, Levato L, Stagno F, Molica S, Martino B, Vigneri P, Di Raimondo F, Morabito F. Flow Cytometric Immunobead Assay for Detection of BCR-ABL1 Fusion Proteins in Chronic Myleoid Leukemia: Comparison with FISH and PCR Techniques. PLoS One 2015; 10:e0130360. [PMID: 26111048 PMCID: PMC4482505 DOI: 10.1371/journal.pone.0130360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/18/2015] [Indexed: 11/19/2022] Open
Abstract
Chronic Myeloid Leukemia (CML) is characterized by a balanced translocation juxtaposing the Abelson (ABL) and breakpoint cluster region (BCR) genes. The resulting BCR-ABL1 oncogene leads to increased proliferation and survival of leukemic cells. Successful treatment of CML has been accompanied by steady improvements in our capacity to accurately and sensitively monitor therapy response. Currently, measurement of BCR-ABL1 mRNA transcript levels by real-time quantitative PCR (RQ-PCR) defines critical response endpoints. An antibody-based technique for BCR-ABL1 protein recognition could be an attractive alternative to RQ-PCR. To date, there have been no studies evaluating whether flow-cytometry based assays could be of clinical utility in evaluating residual disease in CML patients. Here we describe a flow-cytometry assay that detects the presence of BCR-ABL1 fusion proteins in CML lysates to determine the applicability, reliability, and specificity of this method for both diagnosis and monitoring of CML patients for initial response to therapy. We show that: i) CML can be properly diagnosed at onset, (ii) follow-up assessments show detectable fusion protein (i.e. relative mean fluorescent intensity, rMFI%>1) when BCR-ABL1IS transcripts are between 1-10%, and (iii) rMFI% levels predict CCyR as defined by FISH analysis. Overall, the FCBA assay is a rapid technique, fully translatable to the routine management of CML patients.
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Affiliation(s)
| | - Nadia Caruso
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Sabrina Bossio
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
| | | | | | - Stefania Franzese
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Angela Palummo
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
| | - Vincenzo Abbadessa
- Department of Oncology, Hematology and Bone Marrow Transplantation Unit, University of Palermo, Policlinico P. Giaccone, Palermo, Italy
| | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
| | - Clementina Caracciolo
- Department of Oncology, Hematology and Bone Marrow Transplantation Unit, University of Palermo, Policlinico P. Giaccone, Palermo, Italy
| | - Antolino Agostino
- Centro Trasfusionale Ospedale, Azienda Sanitaria Provinciale 7, Ragusa, Italy
| | - Sara Galimberti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luciano Levato
- Medical Oncology Unit, Hematology-Oncology Department, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Fabio Stagno
- Divisione di Ematologia, Ospedale Ferrarotto, Università degli Studi di Catania, Catania, Italy
| | - Stefano Molica
- Medical Oncology Unit, Hematology-Oncology Department, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Bruno Martino
- U.O.C. di Ematologia dell'Azienda"Bianchi-Melacrino-Morelli" di Reggio Calabria, Reggio Calabria, Italy
| | - Paolo Vigneri
- Dipartimento di Scienze Mediche e Pediatriche, Università degli Studi di Catania, Catania, Italy
| | - Francesco Di Raimondo
- Divisione di Ematologia, Ospedale Ferrarotto, Università degli Studi di Catania, Catania, Italy
| | - Fortunato Morabito
- Biotechnology Research Unit, ASP Cosenza, Aprigliano, Italy
- Hematology Unit, Azienda Ospedaliera Annunziata di Cosenza, Cosenza, Italy
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18
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Egan D, Radich J. Prognosis and Molecular Monitoring in Chronic Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S109-13. [DOI: 10.1016/j.clml.2015.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 12/16/2022]
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Deininger MW. Molecular monitoring in CML and the prospects for treatment-free remissions. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:257-263. [PMID: 26637731 DOI: 10.1182/asheducation-2015.1.257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Monitoring treatment responses in chronic myeloid leukemia (CML) is based on complete blood counts (CBCs) to determine hematologic response, karyotyping of bone marrow metaphase cells to delineate cytogenetic response and quantitative reverse transcription polymerase chain reaction (qPCR) to quantify expression of BCR-ABL1 mRNA (molecular response; MR) in peripheral blood. Fluorescence in situ hybridization (FISH) to identify BCR-ABL1 in interphase nuclei and mutational analysis of the BCR-ABL1 kinase domain (KD) are used in certain clinical circumstances. As most patients treated with tyrosine kinase inhibitors (TKIs) achieve complete cytogenetic responses (CCyRs), qPCR with its increased sensitivity and dynamic range has become the main tool used to monitor CML patients. Landmark analyses of large TKI trials have established MR milestones that identify patients with high risk of failure, are the basis of consensus management guidelines, and have led to a strong push toward qPCR test standardization. Today many laboratories report BCR-ABL1 qPCR results on the international scale (IS), a system based on the conversion of laboratory-specific numerical values to conform to a universal scale. The fact that qPCR is technically demanding and liable to assay variations poses considerable challenges for its routine clinical use. This is important as the prevalence of patients on chronic TKI therapy increases and critical clinical decisions are made based on qPCR results, for example if discontinuation of TKI therapy should be considered. Here we will review the current state of molecular monitoring in CML, focusing on qPCR, the definition of TKI failure and the results of TKI discontinuation studies.
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MESH Headings
- Blood Cell Count
- DNA Mutational Analysis
- Fusion Proteins, bcr-abl/metabolism
- Humans
- In Situ Hybridization, Fluorescence
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Medical Oncology/methods
- Mutation
- Polymerase Chain Reaction
- Prognosis
- Protein Kinase Inhibitors/therapeutic use
- Protein Structure, Tertiary
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Remission Induction
- Risk
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Affiliation(s)
- Michael W Deininger
- Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah; and Division of Hematology and Hematologic Malignancies, The University of Utah, Salt Lake City, Utah
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Ye YX, Zhou J, Zhou YH, Zhou Y, Song XB, Wang J, Lin L, Ying BW, Lu XJ. Clinical Significance of BCR-ABL Fusion Gene Subtypes in Chronic Myelogenous and Acute Lymphoblastic Leukemias. Asian Pac J Cancer Prev 2014; 15:9961-6. [DOI: 10.7314/apjcp.2014.15.22.9961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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21
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Mauro MJ. Goals for chronic myeloid leukemia TK inhibitor treatment: how little disease is too much? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:234-239. [PMID: 25696860 DOI: 10.1182/asheducation-2014.1.234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Tyrosine kinase inhibitors, now numbering 5 for the treatment of Philadelphia chromosome-positive leukemia, have proven ability to reduce clonal disease burden rapidly, dramatically, and durably, especially in chronic myeloid leukemia in the chronic phase. Deep molecular remissions are likely in most chronic phase patients and expectations on timing of response have been developed, validated as best as possible, and evolved over time. Increasing attention has been given to the initial decline of Bcr-Abl1 transcripts and the ultimate depth of molecular remission, overshadowing but not displacing the traditional role of cytogenetic response. This chapter reviews the evolution of response milestones for chronic phase chronic myeloid leukemia and tries to answer the question of how little disease is too much.
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Jennings LJ, George D, Czech J, Yu M, Joseph L. Detection and Quantification of BCR-ABL1 Fusion Transcripts by Droplet Digital PCR. J Mol Diagn 2014; 16:174-9. [DOI: 10.1016/j.jmoldx.2013.10.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/04/2013] [Accepted: 10/24/2013] [Indexed: 12/20/2022] Open
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Guérin A, Chen L, Dea K, Wu EQ, Goldberg SL. Economic benefits of adequate molecular monitoring in patients with chronic myelogenous leukemia. J Med Econ 2014; 17:89-98. [PMID: 24188054 DOI: 10.3111/13696998.2013.862251] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Molecular monitoring of chronic myeloid leukemia (CML) has been associated with improved clinical outcomes during tyrosine kinase inhibitor therapy (TKI), yet recent studies have demonstrated its use is far below published guidelines. This study sought to determine frequencies of molecular monitoring and its impact on resource utilization and medical costs. METHODS A retrospective US claims administrative database (IMS LifeLink Health Plan Claims and Truven Health Analytics MarketScan databases, 11/2007-06/2012) was used to analyze the economic impact of qPCR testing in CML patients on first-line TKIs during the initial 12-months of treatment. RESULTS One thousand two hundred and five adult CML patients met the sample selection criteria. Among these, 41.0% had no qPCR tests, 31.9% had 1-2 tests, and 27.1% had 3-4 tests; 88.9% were initiated on imatinib; 47.7% were female. Patients in the 3-4 tests cohort incurred 44% (p < 0.001) fewer in-patient (IP) admissions than patients in the 0-tests cohort. Adjusted all-cause IP cost was $5663 (p = 0.005) lower for the 3-4 tests cohort than the 0-tests cohort. Adjusted progression-related IP cost was $4132 (p = 0.013) lower for the 3-4 tests cohort than the 0-tests cohort. Adjusted medical service cost was $5997 (p = 0.049) lower for the 3-4 tests cohort than the 0-tests cohort. LIMITATIONS Claims databases did not include information on the primary cause of hospitalizations. CONCLUSIONS Among CML patients in two large claims databases, nearly three-quarters did not receive adequate molecular monitoring per published guidelines. Those who were more frequently monitored incurred lower medical service costs, with the majority of the difference in costs being related to disease progression. These findings underscore the clinical and economic values of molecular monitoring in CML.
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Luu MH, Press RD. BCR–ABL PCR testing in chronic myelogenous leukemia: molecular diagnosis for targeted cancer therapy and monitoring. Expert Rev Mol Diagn 2014; 13:749-62. [DOI: 10.1586/14737159.2013.835573] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Elias MH, Baba AA, Azlan H, Rosline H, Sim GA, Padmini M, Fadilah SAW, Ankathil R. BCR-ABL kinase domain mutations, including 2 novel mutations in imatinib resistant Malaysian chronic myeloid leukemia patients-Frequency and clinical outcome. Leuk Res 2014; 38:454-9. [PMID: 24456693 DOI: 10.1016/j.leukres.2013.12.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 12/26/2013] [Accepted: 12/29/2013] [Indexed: 10/25/2022]
Abstract
Discovery of imatinib mesylate (IM) as the targeted BCR-ABL protein tyrosine kinase inhibitor (TKI) has resulted in its use as the frontline therapy for chronic myeloid leukemia (CML) across the world. Although high response rates are observed in CML patients who receive IM treatment, a significant number of patients develop resistance to IM. Resistance to IM in patients has been associated with a heterogeneous array of mechanisms of which point mutations within the ABL tyrosine kinase domain (TKD) are the frequently documented. The types and frequencies of mutations reported in different population studies have shown wide variability. We screened 125 Malaysian CML patients on IM therapy who showed either TKI refractory or resistance to IM to investigate the frequency and pattern of BCR-ABL kinase domain mutations among Malaysian CML patients undergoing IM therapy and to determine the clinical significance. Mutational screening using denaturing high performance liquid chromatography (dHPLC) followed by DNA sequencing was performed on 125 IM resistant Malaysian CML patients. Mutations were detected in 28 patients (22.4%). Fifteen different types of mutations (T315I, E255K, G250E, M351T, F359C, G251E, Y253H, V289F, E355G, N368S, L387M, H369R, A397P, E355A, D276G), including 2 novel mutations were identified, with T315I as the predominant type of mutation. The data generated from clinical and molecular parameters studied were correlated with the survival of CML patients. Patients with Y253H, M351T and E355G TKD mutations showed poorer prognosis compared to those without mutation. Interestingly, when the prognostic impact of the observed mutations was compared inter-individually, E355G and Y253H mutations were associated with more adverse prognosis and shorter survival (P=0.025 and 0.005 respectively) than T315I mutation. Results suggest that apart from those mutations occurring in the three crucial regions (catalytic domain, P-loop and activation-loop), other rare mutations also may have high impact in the development of resistance and adverse prognosis. Presence of mutations in different regions of BCR-ABL TKD leads to different levels of resistance and early detection of emerging mutant clones may help in decision making for alternative treatment. Serial monitoring of BCR-ABL1 transcripts in CML patients allows appropriate selection of CML patients for BCR-ABL1 KD mutation analysis associated with acquired TKI resistance. Identification of these KD mutations is essential in order to direct alternative treatments in such CML patients.
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Affiliation(s)
- Marjanu Hikmah Elias
- Human Genome Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Malaysia
| | - Abdul Aziz Baba
- Haemato-Oncology Unit, Department of Internal Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Malaysia
| | - Husin Azlan
- Haemato-Oncology Unit, Department of Internal Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Malaysia
| | - Hassan Rosline
- Hematology Department, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Malaysia
| | | | | | | | - Ravindran Ankathil
- Human Genome Centre, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Malaysia.
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Abstract
The reciprocal Philadelphia translocation between chromosomes 9 and 22 [t(9;22)(q34;q11)] creates a BCR-ABL1 fusion protein that occurs in approximately 95% of cases of chronic myelogenous leukemia (CML), 15% of cases of adult acute lymphoblastic leukemia, and 5% of adult cases of acute myeloid leukemia. The BCR-ABL1 protein is a constitutively activated tyrosine kinase that induces and maintains the neoplastic phenotype in these leukemias. PCR-based methods to identify and quantitate the tumor-specific BCR-ABL1 RNA have been shown to be an ultrasensitive diagnostic/prognostic tool for Philadelphia-positive leukemias. A novel tyrosine kinase inhibitor (TKI), imatinib, has been confirmed as an effective targeted treatment in most CML patients. A consensus goal for TKI treatment is to achieve a major molecular response (MMR), defined as a 3-log (1,000-fold) reduction in BCR-ABL1 transcripts. Patients who achieve an MMR have been shown to have a significantly reduced risk of disease progression. Conversely, increasing post-therapy BCR-ABL1 RNA levels convey a significantly increased risk of disease progression. The early identification of these high-risk patients may allow early changes to the therapeutic strategy, before frank relapse. Thus, quantitative measurement of BCR-ABL1 transcripts in blood and bone marrow both aids in the initial diagnosis of CML and is essential for routine post-therapy minimal residual disease monitoring. We describe here a method for quantitating BCR-ABL1 transcripts in peripheral blood or bone marrow of CML patients using real-time quantitative reverse transcription PCR (RQ-PCR).
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Einwallner E, Jaeger E, Mitterbauer-Hohendanner G, Bilban M, Simonitsch-Klupp I, Steiner I, Pernicka E, Hoermann G, Herndlhofer S, Sillaber C, Valent P, Schwarzinger I. Endogenous Erythroid Colony Formation in Chronic Myeloid Leukemia: A Recurrent Finding Associated with Persistent Minimal Residual Disease Under Imatinib. Stem Cells Dev 2013; 22:3043-51. [DOI: 10.1089/scd.2013.0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elisa Einwallner
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Jaeger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Martin Bilban
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Irene Steiner
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Pernicka
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Gregor Hoermann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Susanne Herndlhofer
- Division of Hematology and Hemostaseology and Ludwig Boltzmann Cluster Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Sillaber
- Division of Hematology and Hemostaseology and Ludwig Boltzmann Cluster Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- Division of Hematology and Hemostaseology and Ludwig Boltzmann Cluster Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ilse Schwarzinger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
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Mahon FX, Etienne G. Deep molecular response in chronic myeloid leukemia: the new goal of therapy? Clin Cancer Res 2013; 20:310-22. [PMID: 24166905 DOI: 10.1158/1078-0432.ccr-13-1988] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic myeloid leukemia (CML) is caused by formation of the BCR-ABL1 fusion protein. Tyrosine kinase inhibitors (TKI) that target BCR-ABL1 are now the standard of care for patients with CML. Molecular monitoring of residual BCR-ABL1 mRNA transcripts, typically performed using real-time quantitative PCR, has improved treatment management, particularly for patients with CML in chronic phase. Major molecular response (MMR; i.e., a ≥3-log reduction in BCR-ABL1 transcript levels) is used in current treatment guidelines to assess prognosis. Recent evidence suggests that deeper molecular responses (≥4-log reductions in BCR-ABL1 transcript levels), particularly when attained early during treatment, may have even better correlation with long-term outcomes, including survival and disease progression. Furthermore, achieving deep molecular response is a requirement for entering trials evaluating treatment-free remission (TFR). In this review, we discuss the evolving definition of minimal residual disease and the various levels of molecular response under evaluation in current clinical studies. In addition, the available clinical data on achieving MMR and deeper levels of molecular response with TKI therapy, the prognostic value of deep molecular response, and factors that may predict a patient's ability to achieve and sustain a deep molecular response on TKI therapy are also discussed. Available data from TFR studies are addressed. We discuss current knowledge of the ideal conditions for attempting treatment discontinuation, factors predictive of molecular relapse, when TKI therapy should be restarted, and which therapeutic strategies (when administered in the first-line setting and beyond) are expected to best enable successful TFR.
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Affiliation(s)
- François-Xavier Mahon
- Authors' Affiliations: Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Bordeaux and Laboratoire Hématopoïèse Leucémique et Cible Thérapeutique, Biothérapies des maladies génétiques et cancers, Inserm U1035, Université Bordeaux Ségalen; and Centre Régional de Lutte Contre le Cancer de Bordeaux et du Sud-Ouest, Institut Bergonié, Département d'Oncologie Médicale, Bordeaux, France
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Goldberg SL, Chen L, Guerin A, Macalalad AR, Liu N, Kaminsky M, Ericson SG, Wu EQ. Association between molecular monitoring and long-term outcomes in chronic myelogenous leukemia patients treated with first line imatinib. Curr Med Res Opin 2013; 29:1075-82. [PMID: 23738923 DOI: 10.1185/03007995.2013.812034] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Molecular monitoring using quantitative polymerase chain reaction (qPCR) of BCR-ABL mRNA transcripts using the international scale (IS) is recommended by the National Comprehensive Cancer Network and the European LeukemiaNet for patients with chronic myelogenous leukemia in chronic phase (CML-CP). This study assessed the impact of the frequency of qPCR testing on progression-free survival (PFS). RESEARCH DESIGN AND METHODS This retrospective chart review of 402 CML-CP patients on first line imatinib therapy, performed by 38 community-based US physicians, analyzed the impact of the frequency of molecular monitoring on the risk of progression and PFS. MAIN OUTCOME MEASURES Time to progression and progression-free survival. RESULTS Over the 3 year study, 13.2% of patients did not have any qPCR monitoring and 46.3% had 3-4 qPCR tests per year; 5.7% of CML-CP patients progressed to accelerated/blast phase or died. Compared to patients with no qPCR monitoring, those with 3-4 qPCR tests per year had a lower risk of progression (HR = 0.085; p = 0.001) and longer PFS (HR = 0.088; p = 0.001) after adjusting for potential confounders, as did those patients with 1-2 qPCR tests per year (both p < 0.02). Results were consistent after adjusting for Sokal score when available. CONCLUSION This is the first study to document the clinical impact of frequent molecular monitoring, and the findings underscore the importance of regular molecular monitoring in delivering quality care for CML. These findings could be subject to unobserved confounders.
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MESH Headings
- Adult
- Aged
- Antineoplastic Agents/administration & dosage
- Benzamides/administration & dosage
- Blast Crisis/blood
- Blast Crisis/drug therapy
- Blast Crisis/mortality
- Disease-Free Survival
- Female
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/blood
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Male
- Middle Aged
- Monitoring, Physiologic
- Piperazines/administration & dosage
- Polymerase Chain Reaction
- Pyrimidines/administration & dosage
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- Stuart L Goldberg
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA
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30
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Shinohara Y, Takahashi N, Nishiwaki K, Hino M, Kashimura M, Wakita H, Hatano Y, Hirasawa A, Nakagawa Y, Itoh K, Masuoka H, Aotsuka N, Matsuura Y, Takahara S, Sano K, Kuroki J, Hata T, Nakamae H, Mugitani A, Nakane T, Miyazaki Y, Niioka T, Miura M, Sawada K. A multicenter clinical study evaluating the confirmed complete molecular response rate in imatinib-treated patients with chronic phase chronic myeloid leukemia by using the international scale of real-time quantitative polymerase chain reaction. Haematologica 2013; 98:1407-13. [PMID: 23716542 PMCID: PMC3762097 DOI: 10.3324/haematol.2013.085167] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 05/07/2013] [Indexed: 01/30/2023] Open
Abstract
Achievement of complete molecular response in patients with chronic phase chronic myeloid leukemia has been recognized as an important milestone in therapy cessation and treatment-free remission; the identification of predictors of complete molecular response in these patients is, therefore, important. This study evaluated complete molecular response rates in imatinib-treated chronic phase chronic myeloid leukemia patients with major molecular response by using the international standardization for quantitative polymerase chain reaction analysis of the breakpoint cluster region-Abelson1 gene. The correlation of complete molecular response with various clinical, pharmacokinetic, and immunological parameters was determined. Complete molecular response was observed in 75/152 patients (49.3%). In the univariate analysis, Sokal score, median time to major molecular response, ABCG2 421C>A, and regulatory T cells were significantly lower in chronic phase chronic myeloid leukemia patients with complete molecular response than in those without complete molecular response. In the multivariate analysis, duration of imatinib treatment (odds ratio: 1.0287, P=0.0003), time to major molecular response from imatinib therapy (odds ratio: 0.9652, P=0.0020), and ABCG2 421C/C genotype (odds ratio: 0.3953, P=0.0284) were independent predictors of complete molecular response. In contrast, number of natural killer cells, BIM deletion polymorphisms, and plasma trough imatinib concentration were not significantly associated with achieving a complete molecular response. Several predictive markers for achieving complete molecular response were identified in this study. According to our findings, some chronic myeloid leukemia patients treated with imatinib may benefit from a switch to second-generation tyrosine kinase inhibitors (ClinicalTrials.gov, UMIN000004935).
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Benzamides/blood
- Benzamides/therapeutic use
- Female
- Humans
- Imatinib Mesylate
- Internationality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/blood
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Piperazines/blood
- Piperazines/therapeutic use
- Pyrimidines/blood
- Pyrimidines/therapeutic use
- Real-Time Polymerase Chain Reaction/methods
- Real-Time Polymerase Chain Reaction/standards
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Yoshinori Shinohara
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Kaichi Nishiwaki
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Masayuki Hino
- Department of Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Makoto Kashimura
- Division of Hematology, National Health Insurance Matsudo City Hospital, Matsudo, Japan
| | - Hisashi Wakita
- Department of Hematology, Narita Red Cross Hospital, Narita, Japan
| | - Yoshiaki Hatano
- Division of Hematology, Yamamoto Kumiai General Hospital, Noshiro, Japan
| | - Akira Hirasawa
- Department of Hematology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yasuaki Nakagawa
- Department of Internal Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kuniaki Itoh
- Division of Oncology and Hematology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hidekazu Masuoka
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Nobuyuki Aotsuka
- Department of Hematology, Narita Red Cross Hospital, Narita, Japan
| | | | - Sinobu Takahara
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Koji Sano
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Jun Kuroki
- Division of Hematology, Yuri Kumiai General Hospital, Yurihonjo, Japan
| | - Tomoko Hata
- Department of Hematology, Atomic Bomb Disease and Hibakusya Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hirohisa Nakamae
- Department of Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Atsuko Mugitani
- Department of Hematology, Seichokai Fuchu Hospital, Izumi, Japan
| | - Takahiko Nakane
- Department of Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease and Hibakusya Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takenori Niioka
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Kenichi Sawada
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
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31
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Press RD, Kamel-Reid S, Ang D. BCR-ABL1 RT-qPCR for monitoring the molecular response to tyrosine kinase inhibitors in chronic myeloid leukemia. J Mol Diagn 2013; 15:565-76. [PMID: 23810242 DOI: 10.1016/j.jmoldx.2013.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/14/2013] [Accepted: 04/08/2013] [Indexed: 12/16/2022] Open
Abstract
The pathognomonic genetic alteration in chronic myeloid leukemia is the formation of the BCR-ABL1 fusion gene, which produces a constitutively active tyrosine kinase that drives leukemic transformation. Targeted tyrosine kinase inhibitor treatment with imatinib, nilotinib, dasatinib, bosutinib, and ponatinib is the cornerstone of modern therapy for this hematologic malignancy. Real-time quantitative RT-PCR (RT-qPCR, also RQ-PCR) of BCR-ABL1 RNA is a necessary laboratory technique for monitoring the efficacy of tyrosine kinase inhibitor therapy and quantitatively assessing minimal residual disease. The molecular response measured by BCR-ABL1 RT-qPCR assists in identifying suboptimal responses and can help inform the decision to switch to alternative therapies that may be more efficacious (or to pursue more stringent monitoring). Furthermore, the tyrosine kinase inhibitor-mediated molecular response provides valuable risk stratification and prognostic information on long-term outcomes. Despite these attributes, informed, universal, practical utilization of this well-established monitoring test will require heightened efforts by the molecular diagnostics laboratory community to adopt the standardized reporting units of the International Scale. Without widespread adoption of the International Scale, the consensus major molecular response and early molecular response treatment thresholds will not be definable, and optimal clinical outcomes for patients with chronic myeloid leukemia may not be achieved.
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Affiliation(s)
- Richard D Press
- Department of Pathology and Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon 97201, USA.
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32
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Sociedade Brasileira de Patologia, Sociedade Brasileira de Pediatria. Leucemia mieloide crônica. Rev Assoc Med Bras (1992) 2013; 59:220-32. [DOI: 10.1016/j.ramb.2012.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/01/2012] [Indexed: 01/13/2023] Open
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Abstract
With the progress of chronic myeloid leukemia (CML) therapy, the molecular tools used to diagnose and monitor patients have become sophisticated. Despite this, a complete physical examination, complete blood count and bone marrow biopsy with metaphase karyotyping remain standard at diagnosis. Fluorescence in situ hybridization or qualitative reverse transcription polymerase chain reaction are indicated to exclude BCR-ABL1 in Philadelphia chromosome-negative patients with clinically typical CML. Bone marrow karyotyping is the gold standard for monitoring patients on imatinib until achievement of complete cytogenetic response, when quantitative polymerase chain reaction (qPCR) for BCR-ABL1 becomes the method of choice. Quantitative PCR results must be interpreted within a clinical context, the preceding results and performance characteristics of the PCR assay. Expression of qPCR results on the international scale enables comparison of results from different laboratories. BCR-ABL1 kinase domain mutation screening has added another level of complexity that informs the management of some patients with imatinib resistance. Using the entire diagnostic CML armamentarium in a rational and economic fashion can be as challenging as choosing the right treatment. The aim here is to describe what is universally accepted and what is controversial and to provide an update on emerging technologies, while trying to keep an eye on the real world outside specialized centers.
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Affiliation(s)
- Thoralf Lange
- Abteilung für Hämatologie, Onkologie und Hämostaseologie, Universitätsklinikum Leipzig, Germany
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Kantarjian HM, Larson RA, Cortés JE, Deering KL, Mauro MJ. Current practices in the management of chronic myeloid leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2013; 13:48-54. [PMID: 23103085 PMCID: PMC3645375 DOI: 10.1016/j.clml.2012.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 07/26/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND A previous survey of physician self-reported practice patterns in the management of CML was conducted in 2005. The National Comprehensive Cancer Network and European LeukemiaNet guidelines now include nilotinib and dasatinib in their treatment algorithms for CML. To assess these new guidelines, a cross-sectional survey of US hematologists and/or oncologists was conducted in December 2010 through an online survey. MATERIALS AND METHODS The survey had 43 questions consisting of items updated from the 2005 survey to reflect changes in clinical practice, tyrosine kinase inhibitor therapy, and current guidelines. RESULTS Analysis of the responses from 507 board certified medical oncologists/hematologists suggests that the use of imatinib 400 mg as an initial treatment option had decreased from 62% in 2005 to 52% in the 2010 survey. Currently, nearly 40% of physicians would choose either nilotinib or dasatinib as first-line treatment. From the surveyed physicians, achievement of at least a major molecular response (MMR) is the predominant treatment goal in chronic phase CML. CONCLUSION This survey emphasizes the need for continued updates and education regarding optimal therapy, monitoring practices, and therapeutic end points in CML.
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Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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35
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Branford S, Kim DW, Soverini S, Haque A, Shou Y, Woodman RC, Kantarjian HM, Martinelli G, Radich JP, Saglio G, Hochhaus A, Hughes TP, Müller MC. Initial molecular response at 3 months may predict both response and event-free survival at 24 months in imatinib-resistant or -intolerant patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase treated with nilotinib. J Clin Oncol 2012; 30:4323-9. [PMID: 23109697 PMCID: PMC4979159 DOI: 10.1200/jco.2011.40.5217] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 09/05/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The association between initial molecular response and longer-term outcomes with nilotinib was examined. PATIENTS AND METHODS Patients with imatinib-resistant or -intolerant chronic myeloid leukemia in chronic phase from the phase II nilotinib registration study with available postbaseline BCR-ABL1 transcript assessments were included (N = 237). RESULTS BCR-ABL1 transcript levels (International Scale [IS]) at 3 months correlated with complete cytogenetic response (CCyR) by 24 months. Patients with BCR-ABL1 (IS) of > 1% to ≤ 10% at 3 months with nilotinib had higher cumulative incidence of CCyR by 24 months than patients with BCR-ABL1 (IS) of > 10% (53% v 16%). BCR-ABL1 (IS) at 3 months predicted major molecular response (MMR) by 24 months. Cumulative incidence of MMR by 24 months for patients with BCR-ABL1 (IS) of > 0.1% to ≤ 1%, > 1% to ≤ 10%, and > 10% was 65%, 27%, and 9%, respectively. These differences were observed for patients with or without baseline BCR-ABL1 mutations and for those with imatinib resistance or intolerance. Estimated event-free survival (EFS) rates at 24 months decreased with higher transcript levels at 3 months; patients with BCR-ABL1 (IS) of ≤ 1% had an estimated 24-month EFS rate of 82%, compared with 70% for patients with BCR-ABL1 (IS) of > 1% to ≤ 10% and 48% for patients with BCR-ABL1 (IS) of > 10%. CONCLUSION Patients with BCR-ABL1 (IS) of > 10% at 3 months had a lower cumulative incidence of CCyR and MMR and lower rates of EFS versus patients with BCR-ABL1 (IS) of ≤ 10%. Prospective studies may determine whether close monitoring or alternative therapies are warranted for patients with minimal initial molecular response.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Agents/therapeutic use
- Benzamides/therapeutic use
- Disease-Free Survival
- Drug Resistance, Neoplasm
- Fusion Proteins, bcr-abl/biosynthesis
- Fusion Proteins, bcr-abl/genetics
- Humans
- Imatinib Mesylate
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Mutation
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Remission Induction
- Survival Rate
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Susan Branford
- Centre for Cancer Biology, SA Pathology, University of Adelaide, Australia.
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36
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de Souza CA, Pagnano KBB, Bendit I, Conchon M, Freitas CMBDM, Coelho AM, Funke VAM, Bernardo WM. Chronic myeloid leukemia treatment guidelines: Brazilian Association of Hematology, Hemotherapy and Cell Therapy. Brazilian Medical Association Guidelines Project - 2012. Rev Bras Hematol Hemoter 2012; 34:367-82. [PMID: 23125546 PMCID: PMC3486828 DOI: 10.5581/1516-8484.20120094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/13/2012] [Indexed: 01/29/2023] Open
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Chen L, Guérin A, Xie J, Wu EQ, Yu AP, Ericson SG, Jabbour E. Monitoring and switching patterns of patients with chronic myeloid leukemia treated with imatinib in community settings: a chart review analysis. Curr Med Res Opin 2012; 28:1831-9. [PMID: 23127201 DOI: 10.1185/03007995.2012.741577] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Monitoring treatment response is an integral part of chronic myeloid leukemia (CML) treatment. The guidelines recommend regular monitoring using standard methods (e.g., real-time quantitative polymerase chain reaction based on the international scale for molecular response) and treatment adjustment when failure is detected among patients treated with imatinib. The objective of this study was to assess the real-world monitoring and therapy adjustment in this patient population in the US. METHODS Twenty-nine physicians from community practices across the US participated in an online chart review. Adult patients with chronic phase CML who initiated imatinib as first-line therapy during 2006-2010 were selected. Information was collected up to 36 months after imatinib initiation, including response monitoring, response status, and therapy adjustment upon treatment failure. RESULTS The study included 297 eligible patients. By 18 months, 47% of patients had received cytogenetic response assessment continuously as recommended by the guidelines. The corresponding proportion was 39% for continuous molecular response assessment. Among patients who experienced treatment failure by 18 months, only 14%-38% of patients switched to a second-generation tyrosine kinase inhibitor as recommended by the National Comprehensive Cancer Network and the European Leukemia Net guidelines. LIMITATIONS Major limitations included limited generalizability and the inability to accurately assess molecular response due to the variations in testing methods during the study period. CONCLUSIONS Based on the guidelines, the rates of treatment monitoring and switching upon failure were low, demonstrating the need for improvement in CML care in community settings in the US.
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Affiliation(s)
- Lei Chen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936-1080, USA.
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Nichols L, Pippins J, Castle L, Cassler M, Fuller C. Molecular monitoring of chronic myeloid leukemia: a personalized approach to optimizing treatment response. Per Med 2012; 9:727-737. [PMID: 29776270 DOI: 10.2217/pme.12.81] [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: 11/21/2022]
Abstract
Personalized medicine is rapidly developing a purposeful niche in the field of oncology. Monitoring the activity of the oncogenic fusion gene BCR-ABL1 in chronic myeloid leukemia (CML) is a good example of individualizing CML treatment for patients using patient-specific genetic information. However, the frequency at which molecular monitoring for BCR-ABL1 transcripts occurs during treatment with tyrosine kinase inhibitors (TKIs) for CML in clinical practice is much lower than that recommended by either the National Cancer Center Network or the European LeukemiaNet guidelines. Adherence, one of the most critical factors affecting response to TKIs, is often less than desirable and rarely communicated to physicians by patients or managed by care providers. Less than optimal molecular monitoring and low adherence to TKI treatment can lead to rising transcripts levels, that when not detected, have been shown to contribute to poor outcomes. This review reports the basis for and describes the design of a state-of-the-art program intended to improve communication with physicians through real-time messaging about sequential test results for BCR-ABL1 and patients' adherence to TKI therapy.
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Affiliation(s)
- Linda Nichols
- Department of Clinical Practices & Therapeutics, Express Scripts, 100 Parsons Pond Drive, B3-MS2, Franklin Lakes, NJ 07417, USA.
| | - Julie Pippins
- Department of Clinical Practices & Therapeutics, Express Scripts, 100 Parsons Pond Drive, B3-MS2, Franklin Lakes, NJ 07417, USA
| | - Lon Castle
- Department of Clinical Innovations, Express Scripts, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417, USA
| | - Mary Cassler
- Department of Clinical Innovations, Express Scripts, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417, USA
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Triozzi PL, Aldrich W, Achberger S, Ponnazhagan S, Alcazar O, Saunthararajah Y. Differential effects of low-dose decitabine on immune effector and suppressor responses in melanoma-bearing mice. Cancer Immunol Immunother 2012; 61:1441-50. [PMID: 22310929 PMCID: PMC11028937 DOI: 10.1007/s00262-012-1204-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 01/12/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Low doses of the demethylating agent decitabine have been shown to enhance the sensitivity of tumors to immune effector cells and molecules through upregulation of tumor antigen presentation and apoptotic pathways. Effects on host immune effector and suppressor responses have not been well characterized. METHODS Mice bearing B16 melanoma were treated with low-dose decitabine, cytokine, interleukin-2 (IL-2), toll-like receptor 9 agonist ODN1826, and/or a viral vectored vaccine targeting the melanoma antigen Trp2. Lymphoid and myeloid effector and suppressor cells were examined both systemically and intratumorally with functional, flow cytometric, and polymerase chain reaction-based assays. RESULTS Enhancement of tumor growth delay was observed when decitabine was applied sequentially but not concurrently with IL-2. In contrast, complete responses and prolonged survival were observed when decitabine was applied with ODN1826 as therapy and with ODN1826 as a Trp2 vaccine adjuvant. Decitabine decreased natural killer and antigen-specific cellular immune responses when administered concurrently with IL-2 and with ODN1826; the Th1-associated transcription factor Tbet also decreased. T regulatory cells were not affected. When applied concurrently with ODN1826, decitabine increased macrophage cytotoxicity, M1 polarization, and dendritic cell activation. Myeloid-derived suppressor cells were reduced. CONCLUSION Low-dose decitabine promotes both anti- and pro-tumor host immune responses to immunotherapeutics in melanoma-bearing mice. Macrophage effector and dendritic cell activation increase, and myeloid suppressor cells decrease. Lymphoid effector responses, however, can be inhibited.
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Affiliation(s)
- Pierre L Triozzi
- Taussig Cancer Institute, R40, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Yhim HY, Lee NR, Song EK, Yim CY, Jeon SY, Shin S, Kim JA, Kim HS, Cho EH, Kwak JY. Imatinib mesylate discontinuation in patients with chronic myeloid leukemia who have received front-line imatinib mesylate therapy and achieved complete molecular response. Leuk Res 2012; 36:689-93. [DOI: 10.1016/j.leukres.2012.02.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 11/29/2022]
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Comparative study of BCR-ABL1 quantification: Xpert assay, a feasible solution to standardization concerns. Ann Hematol 2012; 91:1245-50. [PMID: 22526369 DOI: 10.1007/s00277-012-1468-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 04/02/2012] [Indexed: 01/07/2023]
Abstract
The level of BCR-ABL1 reached after treatment with tyrosine kinase inhibitors is an effective marker of the therapeutic response and a good survival predictor in chronic myeloid leukemia (CML) patients. However, no agreement has yet been achieved about either the standardization of the technique to determine BCR-ABL1 or the interpretation of the results. The aim of this study was to compare the method currently recommended by the European Leukemia Net, which includes the application of a conversion factor to express the results in international scale, with an automated method (Xpert BCR-ABL™, Cepheid). BCR-ABL1 transcript quantification was performed in 117 samples from CML patients in two different laboratories by both methods, and the results were compared by statistical procedures. A high linear correlation was obtained in the results between the two methods. The concordance at logarithmic intervals reached 62 %. When the major molecular response (MMR) was analyzed, 85 % agreement was achieved. The automated method provides reproducible results and does not show significant differences compared with the traditional method. As a clinical tool, Xpert correctly classified the patients in MMR and can be considered a useful alternative for the molecular follow-up of CML patients.
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Fava C, Kantarjian H, Cortes J. Molecular resistance: an early indicator for treatment change? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2012; 12:79-87. [PMID: 22285607 PMCID: PMC5539978 DOI: 10.1016/j.clml.2011.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 12/01/2011] [Accepted: 12/01/2011] [Indexed: 11/27/2022]
Abstract
Vigilant monitoring of a patient's response to current treatment is imperative to the management of chronic myeloid leukemia (CML). Early identification of treatment failure may increase the probability that alternative therapy will be effective. This review discusses the use of molecular monitoring in the timely detection of failure of imatinib treatment. Changes in the levels of BCR-ABL transcripts are predictive of response or relapse. Patients achieving a major molecular response (MMR) within 12 months of treatment may experience longer cytogenetic remission. Accumulating evidence also suggests that lower transcript levels observed ≤ 6 months after the start of treatment are associated with improved patient outcomes. For patients with primary or secondary imatinib resistance (or intolerance), dasatinib or nilotinib may be prescribed. These agents have demonstrated activity in patients harboring imatinib-resistant BCR-ABL mutations, except for the T315I substitution.
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Jennings LJ, Smith FA, Halling KC, Persons DL, Kamel-Reid S. Design and analytic validation of BCR-ABL1 quantitative reverse transcription polymerase chain reaction assay for monitoring minimal residual disease. Arch Pathol Lab Med 2012; 136:33-40. [PMID: 22208485 DOI: 10.5858/arpa.2011-0136-oa] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Monitoring minimal residual disease by quantitative reverse transcription polymerase chain reaction has proven clinically useful, but as yet there are no Food and Drug Administration-approved tests. Guidelines have been published that provide important information on validation of such tests; however, no practical examples have previously been published. OBJECTIVE To provide an example of the design and validation of a quantitative reverse transcription polymerase chain reaction test. DESIGN To describe the approach used by an individual laboratory for development and validation of a laboratory-developed quantitative reverse transcription polymerase chain reaction test for BCR-ABL1 fusion transcripts. RESULTS Elements of design and analytic validation of a laboratory-developed quantitative molecular test are discussed using quantitative detection of BCR-ABL1 fusion transcripts as an example. CONCLUSIONS Validation of laboratory-developed quantitative molecular tests requires careful planning and execution to adequately address all required analytic performance parameters. How these are addressed depends on the potential for technical errors and confidence required for a given test result. We demonstrate how one laboratory validated and clinically implemented a quantitative BCR-ABL1 assay that can be used for the management of patients with chronic myelogenous leukemia.
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Affiliation(s)
- Lawrence J Jennings
- Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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BCR-ABL1 doubling times more reliably assess the dynamics of CML relapse compared with the BCR-ABL1 fold rise: implications for monitoring and management. Blood 2012; 119:4264-71. [PMID: 22431575 DOI: 10.1182/blood-2011-11-393041] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rising BCR-ABL1 transcripts indicate potential loss of imatinib response in CML. We determined whether the BCR-ABL1 doubling time could distinguish nonadherence from resistance as the cause of lost response. Distinct groups were examined: (1) acquired clinical resistance because of blast crisis and/or BCR-ABL1 mutations; and (2) documented imatinib discontinuation/interruption. Short doubling times occurred with blast crisis (median, 9.0 days; range, 6.1-17.6 days; n = 12 patients), relapse after imatinib discontinuation in complete molecular response (median, 9.0 days; range, 6.9-26.5 days; n = 17), and imatinib interruption during an entire measurement interval (median, 9.4 days; range, 4.2-17.6 days; n = 12; P = .72). Whereas these doubling times were consistently short and indicated rapid leukemic expansion, fold rises were highly variable: 71-, 9.5-, and 10.5-fold, respectively. The fold rise depended on the measurement interval, whereas the doubling time was independent of the interval. Longer doubling times occurred for patients with mutations who maintained chronic phase (CP: median, 48 days; range, 17.3-143 days; n = 29; P < .0001). Predicted short and long doubling times were validated on an independent cohort monitored elsewhere. The doubling time revealed major differences in kinetics according to clinical context. Long doubling times observed with mutations in CP allow time for intervention. A short doubling time for a patient in CP should raise the suspicion of nonadherence.
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Ansstas G, Vij R. Evolution of definitions of response, progression-free survival and event-free survival in front-line studies of chronic myeloid leukemia. Leuk Lymphoma 2012; 53:1273-81. [PMID: 22220824 DOI: 10.3109/10428194.2011.653786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Standardized definitions of response and outcome are useful to evaluate study data, facilitate treatment guideline adherence and aid clinical decision-making. Although definitions of response in chronic myeloid leukemia (CML) have been standardized, definitions of disease progression have not been standardized, despite widespread adoption of the term to reflect development of advanced disease. This article reviews definitions of response and disease progression used for progression-free survival and event-free survival in key CML studies and implications for interpreting patient response. It is proposed that adherence to definitions of progression from the European LeukmiaNet may aid future research and therapeutic decision-making.
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Affiliation(s)
- George Ansstas
- Washington University of St. Louis, St. Louis, MO 63110, USA
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Branford S, Prime J. Chronic myelogenous leukemia: monitoring response to therapy. Curr Hematol Malig Rep 2011; 6:75-81. [PMID: 21360071 DOI: 10.1007/s11899-011-0082-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Molecular monitoring is a key component of the management of patients with chronic myeloid leukemia. The current recommendation is that molecular monitoring be performed in place of cytogenetic assessment when a major molecular response (MMR) is achieved. With the more potent kinase inhibitors nilotinib and dasatinib now approved as front-line therapy, more patients will achieve an MMR and will benefit from molecular monitoring. There is a strong correlation between certain BCR-ABL1 levels and the cytogenetic response, which means that molecular monitoring may act as a surrogate for cytogenetic response, but only if the BCR-ABL1 values are converted to the international reporting scale. Furthermore, improvements in the limit of BCR-ABL1 detection and reduction of intra-assay variability are ongoing issues of importance for molecular monitoring. Standardization of molecular methods to accurately assess the patient response also remains a challenge, despite the recent certification of international scale reference materials.
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Affiliation(s)
- Susan Branford
- Department of Molecular Pathology, Centre for Cancer Biology, SA Pathology and the University of Adelaide, Adelaide, Australia.
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Kantarjian HM, Hochhaus A, Saglio G, De Souza C, Flinn IW, Stenke L, Goh YT, Rosti G, Nakamae H, Gallagher NJ, Hoenekopp A, Blakesley RE, Larson RA, Hughes TP. Nilotinib versus imatinib for the treatment of patients with newly diagnosed chronic phase, Philadelphia chromosome-positive, chronic myeloid leukaemia: 24-month minimum follow-up of the phase 3 randomised ENESTnd trial. Lancet Oncol 2011; 12:841-51. [DOI: 10.1016/s1470-2045(11)70201-7] [Citation(s) in RCA: 391] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Breccia M, Alimena G. The significance of early, major and stable molecular responses in chronic myeloid leukemia in the imatinib era. Crit Rev Oncol Hematol 2011; 79:135-43. [DOI: 10.1016/j.critrevonc.2010.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 07/07/2010] [Indexed: 10/19/2022] Open
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Radich JP. Measuring response to BCR-ABL inhibitors in chronic myeloid leukemia. Cancer 2011; 118:300-11. [PMID: 21717440 DOI: 10.1002/cncr.26280] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/14/2011] [Accepted: 04/21/2011] [Indexed: 12/26/2022]
Abstract
In patients with chronic myeloid leukemia (CML), the hallmark Philadelphia chromosome is the marker of disease that can be detected by conventional metaphase cytogenetics, fluorescence in situ hybridization, or polymerase chain reaction. The current "gold standard" of treatment response is cytogenetic response. Cytogenetic response to imatinib is strongly associated with disease progression and survival. Various strategies aimed at improving cytogenetic response have been explored, such as escalation of imatinib and switching to the newer breakpoint cluster region/v-abl Abelson murine leukemia viral oncogene (BCR-ABL) inhibitors dasatinib and nilotinib. Data from recent randomized trials of dasatinib and nilotinib as first-line therapy of newly diagnosed chronic-phase CML suggest that these agents are more effective than imatinib in achieving 6-month and 12-month complete cytogenetic responses. However, it is still too early to know whether or not this early response will translate into a long-term survival advantage. In addition, more sensitive assays to detect residual disease also may be associated with improved long-term outcomes. The deepest measure of response-a complete molecular response-may help identify patients who can stop taking imatinib for the short term, although the long-term consequences of this strategy remain unknown.
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Affiliation(s)
- Jerald P Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
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